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Cross-national clinical and functional remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study

  • Josep Maria Haro (a1), Diego Novick (a2), Jordan Bertsch (a1), Jamie Karagianis (a3), Martin Dossenbach (a4) and Peter B. Jones (a5)...

Evidence suggests that schizophrenia may have a better outcome for individuals living in low- and middle-income countries compared with affluent settings.


To determine the frequency of symptom and functional remission in out-patients with schizophrenia in different regions of the world.


Using data from the Worldwide-Schizophrenia Outpatient Health Outcomes (W-SOHO) study we measured clinical and functional remission in out-patients with schizophrenia in different regions of the world, and examined sociodemographic and clinical factors associated with these outcomes. The 11 078 participants analysed from 37 participating countries were grouped into 6 regions: South Europe, North Europe, Central and Eastern Europe, Latin America, North Africa and Middle East, and East Asia.


In total, 66.1% achieved clinical remission during the 3-year follow-up (range: 60.1% in North Europe to 84.4% in East Asia) and 25.4% achieved functional remission (range: 17.8% in North Africa and Middle East to 35.0% in North Europe). Regional differences were not explained by participants' clinical characteristics. Baseline social functioning, being female and previously untreated were consistent predictors of remission across regions.


Clinical outcomes of schizophrenia seem to be worse in Europe compared with other regions. However, functional remission follows a different pattern.

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Corresponding author
Josep Maria Haro, Parc Sanitari Sant Joan de Déu, Fundació Sant Joan de Déu, CIBERSAM, Dr. Antoni Pujadas, 42, 08830 – Sant Boi de Llobregat, Barcelona, Spain. Email:
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See editorial, pp. 173–175, this issue.

Declaration of interest

J.M.H is a consultant for Lilly and Lundbeck and has received honoraria from AstraZeneca, Lundbeck and Lilly. D.N., J.K. and M.D. are Lilly employees. J.B. was a statistical consultant for the SOHO study. P.B.J. received grant support from GlaxoSmithKline and honoraria from Bristol-Myers Squibb and Otsuka for lecturing.

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1 World Health Organization. Schizophrenia: An International Follow-up Study. John Wiley and Sons, 1979.
2 Jablensky, A, Sartorius, N, Ernberg, G, Anker, M, Korten, A, Cooper, JE, et al. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organisation ten-country study. Psychol Med Monograph Suppl 1992; 20: 197.
3 Sartorius, N, Jablensky, A, Shapiro, R. Cross-cultural differences in the short-term prognosis of schizophrenic psychoses. Schizophr Bull 1978; 4: 102–13.
4 Leff, J, Sartorius, N, Jablensky, A, Korten, A, Ernberg, G. The International Pilot Study of Schizophrenia: five-year follow-up findings. Psychol Med 1992; 22: 131–45.
5 Harrison, G, Hopper, K, Craig, T, Laska, E, Siegel, C, Wanderling, J, et al. Recovery from psychotic illness: a 15- and 25-year international follow-up study. Br J Psychiatry 2001; 178: 506–17.
6 Hopper, K, Wanderling, J. Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative follow-up project. Schizophr Bull 2000; 26: 835–46.
7 Kulhara, P, Chakrabarti, S. Culture and schizophrenia and other psychotic disorders. Psychiatr Clin North Am 2001; 24: 449–64.
8 Cohen, A, Patel, V, Thara, R, Gureje, O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull 2008; 34: 229–44.
9 Patel, V, Cohen, A, Thara, R, Gureje, O. Is the outcome of schizophrenia really better in developing countries? Rev Bras Psiquiatr 2006; 28: 149–52.
10 Ciompi, L. Catamnestic long-term study on the course of life and aging of schizophrenics. Schizophr Bull 1980; 6: 606–18.
11 Harding, CM, Brooks, GW, Ashikaga, T, Strauss, JS, Breier, A. The Vermont longitudinal study of persons with severe mental illness, II: Long-term outcome of subjects who retrospectively met DSM-III criteria for schizophrenia. Am J Psychiatry 1987; 144: 727–35.
12 Huber, G, Gross, G, Schuttler, R. A long-term follow-up study of schizophrenia: psychiatric course of illness and prognosis Acta Psychiatr Scand 1975; 52: 4957.
13 Ogawa, K, Miya, M, Watarai, A, Nakazawa, M, Yuasa, S, Utena, H. A long-term follow-up study of schizophrenia in Japan – with special reference to the course of social adjustment. Br J Psychiatry 1987; 151: 758–65.
14 Robinson, DG, Woerner, MG, McMeniman, M, Mendelowitz, A, Bilder, RM. Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder. Am J Psychiatry 2004; 161: 473–9.
15 Shepherd, M, Watt, D, Fallon, I, Smeeton, N. The natural history of schizophrenia: a five-year follow-up study of outcome and prediction in a representative sample of schizophrenics. Psychol Med Monogr Suppl 1989; 15: 146.
16 Lambert, M, Schimmelmann, BG, Naber, D, Schacht, A, Karow, A, Wagner, T, et al. Prediction of remission as a combination of symptomatic and functional remission and adequate subjective well-being in 2960 patients with schizophrenia. J Clin Psychiatry 2006; 67: 1690–7.
17 Wunderink, L, Sytema, S, Nienhuis, FJ, Wiersma, D. Clinical recovery in first-episode psychosis. Schizophr Bull 2009; 35: 362–9.
18 Boden, R, Sundstrom, J, Lindstrom, E, Lindstrom, L. Association between symptomatic remission and functional outcomes in first-episode schizophrenia. Schizophr Res 2009; 107: 232–7.
19 Haro, JM, Edgell, ET, Jones, PB, Alonso, J, Gavart, S, Gregor, KJ, et al. The European Schizophrenia Outpatient Health Outcomes (SOHO) Study: rationale, methods and recruitment. Acta Psychiatr Scand 2003; 107: 222–32.
20 Haro, JM, Edgell, ET, Novick, D, Alonso, J, Kennedy, L, Jones, PB, et al. Effectiveness of antipsychotic treatment for schizophrenia: 6-month results of the Pan-European Schizophrenia Outpatient Health Outcomes (SOHO) Study. Acta Psychiatr Scand 2005; 111: 220–31.
21 Dossenbach, M, Arango-Davila, C, Silva Ibarra, H, Landa, E, Aguilar, J, Caro, O, et al. Response and relapse in patients with schizophrenia treated with olanzapine, risperidone, quetiapine, or haloperidol: 12-month follow-up of the Intercontinental Schizophrenia Outpatient Health Outcomes (IC-SOHO) study. J Clin Psychiatry 2005; 66: 1021–30.
22 Haro, JM, Novick, D, Suarez, D, Alonso, J, Lepine, JP, Ratcliffe, M, et al. Remission and relapse in the outpatient care of schizophrenia. Three-year results from the Schizophrenia Outpatient Health Outcomes Study. J Clin Psychopharmacol 2006; 26: 571–8.
23 Dossenbach, M, Pecenak, J, Szuic, A, Irimia, V, Anders, M, Logozar-Perkovic, D, et al. Long-term antipsychotic monotherapy for schizophrenia: disease burden and comparative outcomes for patients with olanzapine, quetiapine, risperidone, or haloperidol monotherapy in a pan-continental observational study. J Clin Psychiatry 2008; 69: 1901–15.
24 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM-IV). APA, 1994.
25 World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO, 1992.
26 Haro, JM, Kamath, SA, Ochoa, S, Novick, D, Rele, K, Fargas, A, et al. The clinical global impression–schizophrenia scale: a simple instrument to measure the diversity of symptoms present in schizophrenia. Acta Psychiatr Scand 2003; 107 (suppl 416): 1623.
27 Haro, JM, Ochoa, S, Gervin, M, Mavreas, V, Jones, P. Assessment of remission in schizophrenia with the CGI and CGI-SCH scales (Letter). Acta Psychiatr Scand 2007; 115: 163–4.
28 Andreasen, NC, Carpenter, WT Jr, Kane, JM, Lasser, RA, Marder, SR, Weinberger, DR. Remission in schizophrenia: proposed criteria and rationale for consensus. Am J Psychiatry 2005; 162: 441–9.
29 Kay, SR, Fiszbein, A, Opler, LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987; 13: 261–76.
30 Nuechterlein, KH, Dawson, ME. A heuristic vulnerability/stress model of schizophrenic episodes. Schizophr Bull 1984; 10: 300–12.
31 Grossman, LS, Harrow, M, Rosen, C, Faull, R. Sex differences in outcome and recovery from schizophrenia and other psychotic and nonpsychotic disorders. Psychiatr Serv 2006; 57: 844–50.
32 Usall, J, Ochoa, S, Araya, S, Marquez, M. Gender differences and outcome in schizophrenia: a 2-year follow-up study in a large community sample. Eur Psychiatry 2003; 18: 282–4.
33 Marshall, M, Lewis, S, Lockwood, A, Drake, R, Jones, P, Croudace, T. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients. Arch Gen Psychiatry 2005; 62: 975–83.
34 Farooq, S, Large, N, Nielssen, O, Waheed, W. The relationship between the duration of untreated psychosis and outcome in low- and-middle income countries: a systematic review and meta analysis. Schizophr Res 2009; 109: 1523.
35 Volkow, ND. Substance use disorders in schizophrenia – clinical implications of comorbidity. Schizophr Bull 2009; 35: 469–72.
36 Buhler, B, Hambrecht, M, Loffler, W, an der Heiden, W, Hafner, H. Precipitation and determination of the onset and course of schizophrenia by substance abuse – a retrospective and prospective study of 232 population-based first illness episodes. Schizophr Res 2002; 54: 243–51.
37 Oosthuizen, P, Emsley, RA, Roberts, MC, Turner, J, Keyter, L, Keyter, N, et al. Depressive symptoms at baseline predict fewer negative symptoms at follow-up in patients with first-episode schizophrenia. Schizophr Res 2002; 58: 247–52.
38 Conley, RR, Ascher-Svanum, HR, Zhu, B, Faries, DE, Kinon, BJ. The burden of depressive symptoms in the long-term treatment of patients with schizophrenia. Schizophr Res 2007; 90: 186–97.
39 Warner, R. Recovery from schizophrenia and the recovery model. Curr Opin Psychiatry 2009; 22: 374–80.
40 Marwaha, S, Johnson, S. Schizophrenia and employment – a review. Soc Psychiatry Psychiatr Epidemiol 2004; 39: 337–49.
41 Thornicroft, G, Brohan, E, Rose, D, Sartorius, N, Leese, M. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet 2009; 373: 408–15.
42 Yanos, PT, Roe, D, Markus, K, Lysaker, PH. Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatr Serv 2008; 59: 1437–42.
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Cross-national clinical and functional remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study

  • Josep Maria Haro (a1), Diego Novick (a2), Jordan Bertsch (a1), Jamie Karagianis (a3), Martin Dossenbach (a4) and Peter B. Jones (a5)...
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Cultures & Course of Schizophrenia

ParthaSarathi Biswas, Psychiatrist
04 January 2012

Since the 1960s, studies on course of schizophrenia indubitably raised the possibility that schizophrenic illness in less-developed nations had a better course and outcome. However, the major limitations ofaccepting this hypothesis were the differences in methodological issues and relative disregard of cultural dimensions. Our thinking about schizophrenia and risks relegation to its course described in literature is regardless of cultural issues. Although the influence of culture was mentioned in cross-cultural WHO studies, but the specific cultural factorscould not be defined [1]. Even the latest publication by Haro et al [2] did not take into account of data on the cultural environment of the participants. They have mentioned the same only in their discussion. The comely editorial by Gureje O and Cohen O [3] boost us up to discuss the degree of the cohort's heterogeneity and thus part of the variability in the course of illness determined by cultural embellishment especially of developing countries.

Some of the favorable unique social dynamics of Third World cultures are a) more kinship networks in society which in turn determines collaborative decision making, b) greater respect to tolerant attitude to difficult behaviors, and c) better family integrity, harmonious relationships, and sociability leading to low-stress, non-competitive productive roles in communal societies and agrarian economics in developing countries [4].

Firstly, incorporating cultural characteristics into the interventionprocess (e.g. involving families in a collaborative effort) rather than institutional and solitary living might have improved the outcome in developing countries [4]. In a contrary, inadequate availability and skeptical views about 'Western' medicine, use of parallel traditional treatment, stigma, and health beliefs (like cultural myths, supernatural explanation of psychiatric disorders) could have influenced health-seekingpathways and thus course of schizophrenia adversely.

In addition, family members generally are not motivated enough to institutionalize patients probably because they a) are able to maintain a symptomatic patient in the community more comfortably, b) usually value the positive symptoms and somatic complaints as important indicator of treatment than negative symptoms and functional impairment, c) stigmatize medication side effects, prolonged and repeated hospitalization more, and d) possess higher level of satisfaction even after partial remission (either spontaneous or following treatment) than Western societies [4]. The schizophrenics with a poor short-term outcome thus are comparatively less likely to seek treatment in developing countries. And resulting attrition of those patients from international studies might have contributed to favorable outcome [5]. On top of that, the threshold for treatability after acute phase is a matter of operational convenience brought about by access to accommodation, rehabilitation services, social benefits, reimbursement and specific national mental health policies. Thus, the outcome definitions may change up with the times and differ across the cultures.

Furthermore, longitudinal empiricism has inevitable hurdles keeping pace with ongoing changes in diagnostic nosology, which is again not culturally amended. And the outcome domains like employment, interpersonalrelations, and self-care operate simultaneously as "open-linked" systems with symptoms, and this dynamic equilibrium can be differentially altered by cultural variations and phase of schizophrenia [6].

Finally, in contrary to our usual assumption of universally shared human response, expressed emotion was found much lower in developing country like India than Western country, especially on the dimension "emotional over-involvement" [7].

To consummate, comparability in course description of schizophrenia is warranted for cross-cultural accumulations of prognostic data in forthcoming studies. The relevant cultural variables or proxy variables for cultural beliefs and practices may be responsible for unexplained variance.


[1] Jablensky A, Sartorius N, Ernberg G, Anker M, Korten A, Cooper JE, et al. Schizophrenia: manifestations, incidence and course in different countries - A World Health Organization Ten Country Study. Psychol Med Monogr Suppl. 1992; 20, 1-97.

[2] Haro JM, Novick D, Bertsch J, Karagianis J, Dossenbach M, Jones PB. Cross-national clinical and functional remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study. Br J Psychiatry 2011, 199:194-201.

[3] Gureje O, Cohen O. Differential outcome of schizophrenia: where we are and where we would like to be. Br J Psychiatry 2011; 199: 173-175.

[4] Versola-Russo J. Cultural and Demographic Factors of Schizophrenia. Int J Psychosoc Rehabil 2006; 10: 89-103.

[5] Kulhara P, Shah R, Grover S. Is the course and outcome of schizophrenia better in the 'developing' world? Asian J Psychiatr 2009; 2:55-62.

[6] Marengo J. Classifying the Courses of Schizophrenia. Schizophr Bull 1994; 20: 519-529.

[7] Jablensky A, Sartorius N, Cooper JE, Anker M, Korten A, BertelsenA. Culture and schizophrenia. Criticisms of WHO studies are answered. Br JPsychiatry 1994, 165:434-436.


Dr. Partha Sarathi Biswas* [1], Ms. Devosri Sen [2], Dr. (Prof.) V.K.Sinha [3]


[1]. Senior Resident, Department of Psychiatry, Ranchi Institute of Neuro-Psychiatry and Allied Sciences (RINPAS), Kanke, Ranchi, India;

[2]. PhD Scholar, Department of Clinical Psychology, Central Institute of Psychiatry (CIP), Ranchi, India;

[3]. Professor of Psychiatry, Central Institute of Psychiatry (CIP), Ranchi, India.

* Corresponding author

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Conflict of interest: None declared

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Schizophrenia outcomes in developing countries

K.A.L.A. Kuruppuarachchi MD, FRCPsych(UK), Professor of Psychiatry
21 November 2011

The article on Cross-national clinical and functional remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study by Haro et al has been read with much interest as it has a global relevance.

Even though studies such as International Pilot Study of Schizophrenia(IPSS), the Determinants of Outcome of Severe Mental Disorder(DOSMeD) and the International Study of Schizophrenia (ISoS) supported thenotion of a better prognosis of schizophrenia in low- and middle- income countries, critics have shown that there were methodological shortcomingsincluding problems in outcome measures used in such studies (Cohen et al 2007). The protective effects of socio- cultural factors including close family support have been suggested as major protective factors. Even though there were methodological problems in previous studies reviews withregard to this subject have demonstrated that supportive and favourable attitudes among family members and social support may contribute to a better outcome in schizophrenia in developing countries( Isaac et al 2007).

However in many developing countries typical extended families are rapidly disappearing and family structure and dynamics are changing at present. On the other hand adverse family influence in the form of high expressed emotions on schizophrenia and the need for reducing exposure tosuch an environment to minimize the relapse of the illness has been highlighted ( Freeman 1980, Koenigsberg and Handley 1986). The potential therapeutic role of families in the care of mental illness has also been highlighted and incorporating family members and having partnership with them in caring process have been discussed (Leggatt 2002).

It is important to pay attention to functional remission as well as to clinical remission , as the final outcome and the productivity of the individual mainly depend on the possibility of integrating him/her back tothe society. Obviously it is important to pay attention to symptomatic recovery also in many instances. It is note worthy that the authors of this study focused attention on the functional remission also. However factors assessed in relation to functional recovery in the area of good social functioning such as positive occupational/vocational status, independent living, active social interactions are anyway better in the developed world compared to the developing countries , whereas readmissionrates which were assessed in the clinical recovery category may be low in low- and middle- income countries as many families in such countries tend to accommodate the patients until they become very difficult to be managedat their home environment. These factors may influence the clinical recovery as well as functional recovery status of the patients. It may be worthwhile noting that centres from South Asia and China( where bulk of the population in the low- and middle-income countries are residing) were not included in the study. Socio-cultural factors in these countries may be different from the rest.

Many previous studies did not seem covering neuro-cognitive symptoms adequately. This domain is important as it is related to functional recovery. Schizophrenia is regarded as a neuro-developmental disorder and the symptamatology is almost identical across the globe. However there maybe difficulties in distinguishing schizophrenia from bipolar disorder globally and presentation of symptoms from one relapse to another may be different creating problems in diagnosis. Unless we use rigerous diagnostic criteria there is a possibility of over inclusion of cases withother illnesses. There is a necessity to do more prospective studies by using robust diagnostic criteria to predict the prognosis . Researchers need to be aware of the fact that there are problems in the records maintained in our part of the world.

It is worthwhile carrying out more methodologically sound prospectivestudies to prove or dispel the existing opinion of good prognosis for schizophrenia in low- and middle- income countries and to shed some light on the protective and vulnerability factors and the importance of identifying compounding variables influencing the recovery process. Early intervention and comprehensive care programmes will benefit the patients globally.


Haro JM, Novick D, Bertsch J et al . Cross-national clinical and functional remission rates: Worldwide Schizophrenia Outpatient Health Outcomes (W-SOHO) study .British Journal of Psychiatry 2011; 199, 194-201

Cohen A, Patel V, Thara R, Gureji O. Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World? Schizophrenia Bulletin 2008; 34(2), 229-244.

Isaac M, Chand P, Murthy P. Schizophrenia outcome measures in the wider international community, British Journal of Psychiatry 2007; 191 (suppl 50):s71-s77.

Freeman HL. Coping with schizophrenia .British Journal of Hospital Medicine 1980 ; 54-58.

Koenigsberg HW, Handley R. Expressed Emotion: From Predictive Index to Clinical Construct. The American Journal of Psychiatry 1986; 143:11 , 1361-1373.

Leggatt M. Families and mental health workers: the need for partnership. World Psychiatry 2002 ; 1:1, 52-54.

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Conflict of interest: None declared

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