The Ten Country Study - Schizophrenia

The IPSS was followed by another study coordinated by the WHO, the Ten Country Study described above (Sartorius et al.,  1986;  Jablensky et al.,  1992).  Data on outcome after 2 years were obtained for 78% (n=1078) of the original sample. The outcome for patients diagnosed with broad schizophrenia was more favourable in developing countries than in developed countries, for example, on five of the six measures of ‘best outcomes’ examined.

Though limited,  these reports support the view that patients fare better,  on average, in the developing countries. Additional evidence from follow-up at the Chandigarh sites raises the possibility that there may be greater variability in outcomes in developing countries (Mojtabai et al., 2001).

In Chandigarh, there was a group of subjects that did poorly in the first 2 years (n=15); nearly half had died by the time of the 15-year follow-up. In two patients, malnutrition was a contributing cause of death. These findings are generally consistent with another study conducted in Brazil. Menezes and Mann (1996) carried out a 2-year follow-up of a prevalent sample of 120 patients with schizophrenia who had been consecutively admitted to psychiatric hospitals of a catchment area of Sao Paulo, Brazil and found an eightfold increased risk of dying compared with the general population (standardized mortality ratio 8.4), and a dramatically increased risk for suicide.

Several explanations of the fundamental differences in outcome between developed and developing countries in the Ten Country Study beg consideration.

Artifact is one potential explanation. It is possible that the disease ‘mix’ in developing countries (higher incidence of non-S+  schizophrenia,  higher proportion NARP)  is at the foundation of the improved prognosis.  However,  improved or better course and outcomes apply to both acute and nonacute onset disease, and that broadly and narrowly defined (Jablensky et al., 1992).

The ‘mix’ may be different, but it does not explain all of the difference in prognosis. Other explanations relating to background characteristics of the underlying samples and ascertainment bias have been considered (Jablensky et al., 1992; Hopper and Wanderling, 2000); however, none has been shown to account for the difference.

Michaeline Bresnahan, Paulo Menezes, Vijoy Varma and Ezra Susser
Division of Epidemiology, Columbia University, New York, USA
Department of Preventative Medicine, University of Sao Paulo, Brazil


  • Bamrah JS, Freeman HL, Goldberg DP (1991) Epidemiology of schizophrenia in Salford, 1974 - 84. Changes in an urban community over ten years. British Journal of Psychiatry 159, 802 - 810.
  • Bell MD, Lysaker PH (1997) Clinical benefits of paid work activity in schizophrenia: one year follow-up. Schizophrenia Bulletin 23, 317 - 328.
  • Bhugra D, Hilwig M, Hossein B et al. (1996) First-contact incidence rates of schizophrenia in Trinidad and one-year follow-up. British Journal of Psychiatry 169, 587 - 592.
  • Bhugra D, Leff J, Mallett R, Der G, Corridau B, Rudge S (1997) Incidence and outcome of schizophrenia in whites, African Caribbeans and Asians in London. Psychological Medicine 27, 791 - 798.
  • Bresnahan MA, Brown AS, Schaefer CA, Begg MD, Wyatt RJ, Susser ES (2000) Incidence and cumulative risk of treated schizophrenia in the Prenatal Determinants of Schizophrenia study. Schizophrenia Bulletin 26, 297 - 308.
  • Brewin J, Cantwell R, Dalkin T et al. (1997) Incidence of schizophrenia in Nottingham. A comparison of two cohorts, 1978 - 80 and 1992 - 94. British Journal of Psychiatry 171, 140 - 144.
  • Brown GH, Bone M, Dalison B, Wing JK (1966) Schizophrenia and Social Care. London: Oxford University Press.
  • Carpenter WT, Strauss JS (1991) The prediction of outcome in schizophrenia IV: Eleven-year follow-up of the Washington IPSS cohort. Journal of Nervous and Mental Disease 179, 517 - 525.
  • Collins PY, Wig NN, Day R et al. (1996) Psychosocial and biological aspects of acute brief psychoses in three developing country sites. Psychiatric Quarterly 67, 177 - 193.
  • Collins PY, Varma VK, Wig NN, Mojtabai R, Day R, Susser E (1999) Fever and acute brief psychosis in urban and rural settings in north India. British Journal of Pyschiatry 173, 520 - 524.
  • d'Arcy C, Rawson NSB, Lydick E, Epstein R (1993) The Epidemiology of Treated Schizophrenia
  • Saskatchewan 1976 - 1990. Gronigen, the Netherlands: World Psychiatric Association, Section of Epidemiology and Community Psychiatry.
  • Dube KC, Kumar N, Dube S (1984) Long term course and outcome of the Agra cases in the International Pilot Study of Schizophrenia. Acta Psychiatrica Scandinavica 70, 170 - 179.
  • Eaton WW (1999) Evidence for universality and uniformity of schizophrenia around the world: assessment and implications. In Search for the Causes of Schizophrenia, Vol. IV: Balance of the Century, WF Gattaz and H Hafner, eds. Berlin: Springer-Verlag, pp. 21 - 33.
  • German N (1972) Aspects of clinical psychiatry in sub-Saharan Africa. British Journal of Psychiatry 121, 461 - 479.
  • Goater N, King M, Cole E et al. (1999) Ethnicity and outcome of psychosis. British Journal of Psychiatry 175, 34 - 42.
  • Harrison G, Mason P, Glazebrook C, Medley I, Croudace T, Docherty S (1994) Residence of incident cohort of psychotic patients after 13 years of follow up. British Medical Journal 308, 813 - 816.
  • Harrison G, Croudace T, Mason P, Glazebrook C, Medley I (1996) Predicting the long-term outcome of schizophrenia. Psychological Medicine 26, 697 - 705.
  • Helgason L (1990) Twenty years' follow-up of first psychiatric presentation for schizophrenia: what could have been prevented? Acta Psychiatrica Scandinavica 81, 231 - 235.
  • Hickling FW, Rodgers-Johnson P (1995) The incidence of first contact schizophrenia in Jamaica. British Journal of Psychiatry 167, 193 - 196.
  • Hopper K, Wanderling J (2000) Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: Results from ISoS, the WHO colloaborative follow-up project. Schizophrenia Bulletin 26, 835 - 846.
  • Iancano WG, Beiser M (1992) Are males more likely than females to develop schizophrenia? American Journal of Psychiatry 149, 1070 - 1074.
  • Jablensky A, Sartorius N, Ernberg G et al. (1992) Schizophrenia: manifestations, incidence and course in different cultures. Psychological Medicine, Monograph Supplement 20. Cambridge: Cambridge University Press.
  • Kulhara P, Wig NN (1978) The chronicity of schizophrenia in North West India: results of a follow-up study. British Journal of Psychiatry 132, 186 - 190.
  • Lambo TA (1960) Further neuropsychiatric observations in Nigeria. British Medical Journal 2, 1696 - 1704.
  • Lee PWH, Lieh-Mak F, Wong MC, Fung ASM, Mak KY, Lam J (1998) The 15-year outcome of Chinese patients with schizophrenia in Hong Kong. Canadian Journal of Psychiatry 43, 706 - 713.
  • Leff J, Wig NN, Gosh A et al. (1987) Influence of relatives' expressed emotion on the course of schizophrenia in Chandigarh. British Journal of Psychiatry 151, 166 - 173.
  • Leff J, Sartorius N, Jablensky A, Korten A, Ernberg G (1992) The International Pilot Study of Schizophrenia: five year follow-up findings. Psychological Medicine 22, 131 - 145.
  • Leon CA (1989) Clinical course and outcome of schizophrenia in Cali, Columbia: a 10-year follow-up study. Journal of Nervous and Mental Disease 177, 593 - 606.
  • Lo WH, Lo T (1977) A ten-year follow-up study of Chinese schizophrenics in Hong Kong. British Journal of Psychiatry 131, 63 - 66.
  • Mahy G, Mallett R, Leff J, Bhugra D (1999) First-contact incidence rate of schizophrenia on Barbados. British Journal of Psychiatry 175, 28 - 33.
  • Mason P, Harrison G, Glazebrook C, Medley I, Dalkin T, Croudace T (1995) Characteristics of outcome in schizophrenia at 13 years. British Journal of Psychiatry 167, 596 - 603.
  • Mason P, Harrison G, Glazebrook C Medley, I Croudace T (1996) The course of schizophrenia over 13 years. A report from the International Study on Schizophrenia (ISoS) coordinated by the World Health Organization (1996) British Journal of Psychiatry 169, 580 - 586.
  • Mason P, Harrison G, Croudace T, Glazebrook C, Medley I (1997) The predictive validity of a diagnosis of schizophrenia. British Journal of Psychiatry 178, 321 - 327.
  • Menezes PR, Mann AH (1996) Mortality among patients with nonaffective functional psychoses in the city of Sao Paulo. Revista de Saude Publica 30, 304 - 309.
  • Mojtabai R, Varma VK, Malhotra S et al. (2001) Mortality and long-term course in schizophrenia with a 2-year poor course: a study in a developing country. British Journal of Psychiatry 178, 71 - 75.
  • Murphy HBM, Raman AC (1971) The chronicity of schizophrenia in indigenous tropical peoples: results of a twelve-year follow-up survey. British Journal of Psychiatry 118, 489 - 497.
  • Ninulaain M, O'Hare A, Walsh D (1987) Incidence of schizophrenia in Ireland. Psychological Medicine 17, 943 - 948.
  • Rajkumar S, Padmavati R, Thara R, Sarada Menon M (1993) Incidence of schizophrenia in an urban community in Madras. Indian Journal of Psychiatry 35, 18 - 21.
  • Rin H, Lin TY (1962) Mental illness among Formosan Aborigines as compared with the Chinese in Taiwan. Journal of Mental Science 108, 134 - 146.
  • Sartorius N, Jablensky A, Korten A et al. (1986) Early manifestations and first-contact incidence of schizophrenia in different cultures. Psychological Medicine 16, 909 - 928.
  • Scottish Schizophrenia Research Group (1992) The Scottish first episode schizophrenia study VIII. Five-year follow-up: clinical and psychosocial findings. British Journal of Psychiatry 161, 496 - 500.
  • Shepherd M, Watt D, Falloon I, Smeeton N (1983) The natural history of schizophrenia: a five year follow-up study of outcome and prediction in a representative sample of schizophrenics. Psychological Medicine, Monograph Supplement 15. Cambridge: Cambridge University Press.
  • Susser E, Wanderling J (1994) Epidemiology of nonaffective acute remitting psychosis vs schizophrenia. Archives General Psychiatry 51, 294 - 301.
  • Susser E, Collins P, Schanzer B, Varma VK, Gittelman M (1996) Can we learn from the care of persons with mental illness in developing countries? American Journal of Public Health 86, 926 - 928.
  • Susser E, Varma VK, Mattoo SK et al. (1998) Long-term course of acute brief psychosis in a developing country setting. British Journal of Psychiatry 173, 226 - 230.
  • Thara R, Henrietta M, Joseph, A, Rajkumar S, Eaton WW (1994) Ten-year course of schizophrenia - the Madras longitudinal study. Acta Psychiatrica Scandinavica 90, 329 - 336.
  • Tsoi WF, Wong KE (1991) A 15-year follow-up study of Chinese schizophrenic patients. Acta Psychiatrica Scandinavica 84, 1248 - 1253.
  • United Nations Development Programme (1998) Human Development Report. New York: United Nations.
  • Vazquez-Barquero JL, Cuesta Nunez MJ, de la Varga M et al. (1995) The Cantabria first episode schizophrenia study: a summary of general findings. Acta Psychiatrica Scandinavica 91, 156 - 162.
  • Warner R (1985) Recovery from Schizophrenia: Psychiatry and Political Economy. London: Routledge & Kegan Paul.
  • Waxler NE (1979) Is outcome for schizophrenia better in non-industrial societies? The case of Sri Lanka. Journal of Nervous and Mental Disease 167, 144 - 158.
  • Wig NN, Menon DK, Bedi H et al. (1987) Distribution of expressed emotion component in relatives of schizophrenic patients in Aarhus and Chandigarh. British Journal of Psychiatry 151, 160 - 165.
  • Wiersma D, Nienhuis FJ, Sloott CJ, Giel R (1998) Natural course of schizophrenic disorders: a 15-year follow-up of a Dutch incidence cohort. Schizophrenia Bulletin 24, 75 - 85.
  • World Health Organization (1973) The International Pilot Study of Schizophrenia. Vol. 1. Geneva: World Health Organization.
  • World Health Organization (1979) Schizophrenia: An International Follow-up Study. Chichester, UK: Wiley.
  • World Health Organization (1992) Manual of International Statistical Classification of Diseases, Injuries and Causes of Death, 10th edn. Geneva: World Health Organization.

Provided by ArmMed Media