When yer stupid n arrogant, ya make things up

http://www.washingtonpost.com/wp-dyn/content/article/2005/06/26/AR2005062601091_pf.html
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Social Network's Healing Power Is Borne Out in Poorer Nations

By Shankar Vedantam
Washington Post Staff Writer
Monday, June 27, 2005; A01



RAIPUR RANI, India -- Second of three articles

Psychiatrist Naren Wig crossed an open sewer, skirted a pond and, in
the dusty haze of afternoon, saw something miraculous.

Krishna Devi, a woman he had treated years ago for schizophrenia, sat
in a courtyard surrounded by religious pictures, exposed brick walls
and drying laundry. Devi had stopped taking medication long ago, but
her articulate speech and easy smile were eloquent testimony that she
had recovered from the debilitating disease.

Few schizophrenia patients in the United States are so lucky, even
after years of treatment. But Devi had hidden assets: a doting family
and an embracing village that never excluded her from social events,
family obligations and work.

Devi is a living reminder of a remarkable three-decade-long study by
the World Health Organization -- one that many Western doctors
initially refused to believe: People with schizophrenia, a deadly
illness characterized by hallucinations, disorganized thinking and
social withdrawal, typically do far better in poorer nations such as
India, Nigeria and Colombia than in Denmark, England and the United
States.

The astounding result calls into question one of the central tenets of
modern psychiatry: that a "brain disease" such as schizophrenia is best
treated by hospitals, drugs and biomedical interventions.

European and U.S. psychiatrists were so shocked by the initial findings
in the 1970s that they assumed something was wrong with the study. They
repeated it. The second trial produced the same result. The best
explanation, researchers concluded, is that the stronger family ties in
poorer countries have a profound impact on recovery.

"If you have a cardiovascular problem, I would prefer to be a citizen
in Los Angeles than in India," said Benedetto Saraceno, director of the
department of mental health and substance abuse at WHO's headquarters
in Geneva. "If I had cancer, I would prefer to be treated in New York
than in Iran. But if you have schizophrenia, I am not sure I would
prefer to be treated in Los Angeles than in India."

Most people with schizophrenia in India live with their families or
other social networks -- in sharp contrast to the United States, where
most patients are homeless, in group homes or on their own, in
psychiatric facilities or in jail. Many Indian patients are given
low-stress jobs by a culture that values social connectedness over
productivity; patients in the United States are usually excluded from
regular workplaces.

Indian families sit in on doctor-patient discussions because families
are considered central to the problem and the solution. In America,
doctor-patient conversations are confidential -- and psychiatrists
primarily focus on brain chemistry.

Norman Sartorius, the former head of WHO's mental health program,
spearheaded the schizophrenia studies. He says there is much the United
States and Europe could learn from villages such as Raipur Rani.

In an interview at his home in Geneva, he said Western countries could
financially help families take care of their relatives, which would
save money on hospitalization and incarceration. Caregivers might be
given time off from jobs. And doctors could enlist recreational and
religious groups to replace the social networks that patients lose.

"Social factors play a major and important role in the outcome of
disease," Sartorius said. "Very few solutions are medical in medicine."

Decades of research have supported the WHO findings, but they have met
with stony silence in the United States, in part because
anti-psychiatry groups have argued erroneously that the studies prove
that drugs and doctors are useless. Most U.S. psychiatrists see
schizophrenia as an organic brain disorder, whose origins and outcome
depend on genes and brain chemistry. They acknowledge the psychosocial
aspects of disease, but the challenges of connecting patients with
jobs, schooling and social networks are neglected -- often because they
fall outside the bounds of traditional medicine.

Asked whether he would agree that schizophrenia patients might be
better off in Nigeria than in New York, Darrel Regier, director of
research at the American Psychiatric Association, was blunt: "God, no!"

Regier is not alone. Patient advocacy groups are also uneasy about
giving families a central role because, in a previous era, a
now-discredited theory blamed schizophrenia on poor parenting.

Drug manufacturers, too, are focused elsewhere. "Pharmaceutical
companies, which control the scientific production of research at
universities, are not interested in saying, 'Social factors are more
important than my drug,' " said Jose Bertolote, a WHO psychiatrist.
"I'm not against the use of medication, but it's a question of
imbalance."

Western doctors cannot write prescriptions for stronger family ties,
Bertolote said. But Indian psychiatrists, unlike their Western
counterparts, dispense not only drugs but also spiritual advice, family
counseling -- even matchmaking services. Indian doctors are seen not
only as medical experts, but as wise authority figures.

In the south Indian city of Chennai, psychiatrist Shantha Kamath writes
prescriptions for better family ties: When a father asked for her help
in arranging the marriage of his daughter, who has schizophrenia,
Kamath's written instructions told the parents how to interact with
their daughter and listed the skills the young woman needed to learn
before the doctor would arrange a match.

Trend Emerged Slowly

The International Pilot Study on Schizophrenia was launched in 1967 to
determine whether the disease existed in all countries and whether it
could be reliably diagnosed and treated.

The study quickly established that the disease occurs everywhere. Only
gradually did it emerge that patients in poor nations had better
outcomes. The second study, which had more rigorous guidelines,
included Naren Wig's patients in Raipur Rani village.

In all, the study tracked about 3,300 patients, Sartorius said, and
30-year follow-ups confirmed the initial trends. The study spanned a
dozen countries -- capitalist and communist, eastern and western,
northern and southern, large and small, rich and poor.

The results were consistent -- and surprising. Patients in poorer
countries spent fewer days in hospitals, were more likely to be
employed and were more socially connected. Between half and two-thirds
became symptom-free, whereas only about a third of patients from rich
countries recovered to the same degree, Sartorius said.

Nigerian, Colombian and Indian patients also seemed less likely to
suffer relapses and had longer periods of health between relapses.
Doctors in poorer countries stopped drugs when patients became better
-- whereas doctors in rich countries often required patients to take
medication all their lives.

A separate study, in rural China, recently revealed that low doses of
medication could be as effective as high doses, and virtually
eliminated side effects, said Martin Gittelman, a clinical professor of
psychiatry at New York University. And older medications, largely
discarded in wealthier countries, were as effective as newer, expensive
anti-psychotic drugs.

The secret? The "hand labor" of extended families and primary care
workers to constantly monitor patients and bump up medication dosages
at the earliest sign of psychotic flare-ups, Gittelman said. Nuclear
families in more urbanized societies are often unable to provide that
kind of help and monitoring, he added: "Urban Shanghai may look closer
to urban New York than to rural China."

"A culture like ours is oriented around individual autonomy and
accomplishment," said William Carpenter, a psychiatrist at the
University of Maryland in Baltimore who helped run a wing of the WHO
study in the Washington area. In countries such as Denmark, "if you
were psychotic, you were on disability for life. Virtually nobody who
had schizophrenia had a job."

In country after country, WHO found that strong social and family
connections trumped high-tech medical facilities. Wig, the Indian
psychiatrist, had just launched a psychiatry department in the northern
Indian city of Chandigarh when the second phase of the WHO study began
in 1978. He had no nurses. Out of necessity, he asked families to stay
with patients 24 hours a day. Relatives became the nurses. The practice
persists to this day.

The tight security found at most American psychiatric wards is absent
in Chandigarh: For one thing, it is unaffordable, but Wig also found
that relatives are more effective than strangers in calming agitated
patients.

Patients at the Chandigarh hospital today pay a dollar a day. That
includes meals. As the WHO study got underway, Wig realized there were
many patients in India who could not afford even the inexpensive
hospital care. The study therefore included patients in the nearby
village of Raipur Rani, where doctors could dispense outpatient care.

Krishna Devi was 22 when she was enrolled in the study. Doctors noted
that her thinking was disordered -- she talked about irrelevant things
and turned aggressive without reason. She was paranoid and hallucinated
that a man was chasing her, said Arun Misra, a psychiatrist who treated
her and maintained neat, handwritten records in bound folders of
now-yellowing sheets of paper.

The villagers had their own explanations for Devi's behavior -- no one
had heard of schizophrenia. And Devi's odd behavior was seen as no
reason to keep her isolated. She got married and had five children.
Devi's husband, a potter, was supportive, as were other relatives.
Neighbors helped too, and in time, she said, she got better.

Wig, who trained as a psychiatrist in England, keeps up with the latest
research, but mostly he tells his patients about religious figures who
overcame obstacles. He never tells them schizophrenia is a chronic,
incurable brain disease. And he encourages patients to complement his
treatment with faith-healing techniques.

"In India, people do not accept the medical model of schizophrenia,"
Wig said. "The medical model says, 'This is a genetic, biochemical
thing and you have to keep giving medicine and there is nothing else
that can be done.' . . . Indian patients continue to sustain hope."

Families Play a Crucial Role

Lakshmi Ramachandran lived in Detroit, but she decided to take her son
back to India after he was diagnosed with schizophrenia in his early
twenties. The family had moved to the United States when Rajesh was 2,
but after he fell ill it was decided he would do better in Chennai.

"He likes the crowds -- in Detroit, you had to motivate yourself to
socialize," the mother said in an interview in Chennai. "Here, the
neighbors come and ask, 'Hi, Rajesh, how are you?' "

Families are the reason Indian patients have better outcomes, said
psychiatrist R. Thara Srinivasan, who heads a nonprofit treatment
facility called the Schizophrenia Research Foundation (SCARF) in
Chennai. The foundation has independently verified the WHO study
results.

"My theory is that the family here ensures they take medication
properly," said the psychiatrist, who prefers to be identified by the
single name Thara. "Compliance is a problem in the West."

If patients refuse medication, Thara instructs families to crush the
pills and disguise the medicine in food. During a reporter's visit,
another SCARF psychiatrist, Shantha Kamath, paid a small amount of
money to her patient for taking an anti-psychotic injection -- a reward
he has now come to expect.

Westerners have criticized such practices, but Thara argues that
patient-doctor relationships in India are fundamentally different from
those in America: The relationships may be paternalistic, but the
benefits are lower costs and less fragmentation. On an annual budget of
$67,000, SCARF treats 1,200 patients, dispenses free drugs, runs three
residential facilities for 150 patients and offers vocational training
each day for 100 patients.

Social connectedness for patients is seen as so important that the
psychiatrists tell families to secretly give money to employers so that
patients can be given fake jobs, work regular hours and have the
satisfaction of getting "paid" -- practices that would be unethical,
even illegal, in the United States.

While work and family are clearly beneficial for patients, Thara
acknowledged that caregivers, who are usually women, pay a price.

"My parents told me to get married," said one Chennai woman, C. Chitra,
whose marriage was arranged when she was 23. Her in-laws, who came from
a wealthier family, had told her only that her husband-to-be sometimes
"got angry."

Chitra thought nothing of it: "Everyone gets angry."

But her 34-year-old husband had schizophrenia. "He hit me without
reason," she said.

Chitra did not consider divorce: She felt her options as a poor,
divorced woman would be worse. Shortly thereafter, her husband's
brother moved in with them -- and he had schizophrenia, too. Chitra
cared for both men, dealt with their psychoses and calmed them when
they turned violent.

Her husband slowly got better. Chitra had a baby, and she said she
finally is happy. But when her in-laws wanted to arrange a marriage for
her husband's brother, she put her foot down. She did not want another
woman to go through what she had endured.

Battling Social Withdrawal

Prince George's County outside Washington was one of the sites of the
pioneering WHO study -- William Carpenter helped treat about 90
schizophrenia patients at three hospitals. That experience brought home
to him the fact that medications primarily control patients' delusions
and hallucinations, not the "negative" symptoms that cause patients to
disappear into silent, inner worlds.

"The bias has always been in the direction of reducing psychosis," said
Carpenter, director of the Maryland Psychiatric Research Center.
"Psychosis is public and bothersome. . . . Negative symptoms bother you
if it's your child, but it doesn't create a public disturbance."

Anti-psychotic drugs that help quell the outward symptoms may actually
exacerbate social withdrawal, he said: "While we treat one part of the
illness, we potentially complicate another part of the illness."

New medicines are being aimed at the negative symptoms. But Carpenter
and other experts said it is clear that drugs cannot replace social
supports.

Treating schizophrenia without anti-psychotic drugs is unthinkable, Wig
and Saraceno said. But the current system in wealthy countries merely
brings patients who are in crisis into hospitals, stabilizes them with
drugs and discharges them after a few days. Saraceno said that approach
is doomed to end in a new crisis -- the familiar "revolving door."

Ronald Manderscheid, a public health expert at the U.S. Substance Abuse
and Mental Health Services Administration, said policymakers have come
to understand that the key to treating schizophrenia lies in
integrating cultural and social supports with medicine, as villages
such as Raipur Rani have long done.

"Is it possible that a mental health system which is poor, deprived,
with no resources, no drugs is providing better and more humane and
sensible service to the population rather than in rich countries?"
WHO's Saraceno asked. "Good mental health service doesn't require big
technologies but human technologies. Sometimes, you get better human
technologies in the streets of Rio than in the center of Rome."

© 2005 The Washington Post Company

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