How does Culture Improve Mental Health?

If you or a loved one had schizophrenia, where do you think you would have a better long term outcome: in the USA, or in a developing country?  The answer is probably not what you think.  The World Health organization commissioned a series of studies looking at the long-term effects of mental illness worldwide.  They examined rates of recovery and relapse, and compared them between countries.  In their final report, they stated that individuals with schizophrenia living in developing countries had the lowest rates of relapse, and had better long-term health than those living in developed nations.

These findings were received with skepticism for a variety of reasons. Researchers did not clearly state how they defined “developed” and “developing” countries.  This resulted in Hong Kong being classified as a developing country. At the end of the report, the researchers suggested that better outcomes existed in developing countries because of “collectivistic culture” Collectivist culture broadly refers to the idea that some societies better integrate all individuals into the community. For example, in an agricultural society where many hands are needed to complete labor related to harvest it becomes important to have every member of a family contribute to production. This includes individuals who may deal with physical or mental challenges. The fact that individuals dealing with mental health disorders may be better integrated into the family and/or communities activities is thought to somehow promote better outcomes. Perhaps people living with schizophrenia in “developing” countries may experience more social support through “collectivism.” This would be an interesting finding, but because the researchers did not define or actually examine collectivism, it remained unclear what forces were actually responsible for the better health outcomes for individuals outside of the developed world.

Hopper and Wanderling (2000) re-examined the finding that individuals diagnosable for schizophrenia have better long-term outcomes than individuals with the same diagnosis in developed countries.  They examined data collected over a period of 13 years, and tried to account for bias in this data. Despite these controls the finding still holds true that individuals diagnosable for schizophrenia have better outcomes in developing countries than those in developed countries. What remains unknown is whether these findings still hold true in developing contexts outside of India. Once Hong Kong was reclassified as “developed” the only sites left in the developing category were located in India.

Beyond this, the international mental health community still needs to closely examine what elements of “culture” foster better outcomes in one setting and potentially hinder positive long-term outcomes for individuals diagnosable for schizophrenia in another setting. In a field like psychology, experimental design studies usually provide the gold standard for rigorous research. Yet the lack of understanding about how mechanisms’ within “culture” contribute to better outcomes among those living with schizophrenia, provides a prime example of how [qualitative, descriptive research can compliment traditional modes of inquiry and shed light on valuable information]. The developed versus developing country distinction in outcomes for people diagnosable with schizophrenia illustrates the need to integrate more descriptive, qualitative research into the study of psychopathology.

results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia. Schizophrenia bulletin, 26 (4), 835-46 PMID: 11087016