Cross-Cultural Perspective of Schizophernia

Cross-Cultural Perspective of Schizophrenia
Christine Griffith
Marywood University
July 24, 2010
Abstract

This paper takes a cross-cultural perspective by examining the diagnosis and issues of schizophrenia in the Dominican Republic, Ethiopia, Somalia, and the United States. In particular issues related to gender, age, sexual orientation, race, and socioeconomic status are identified. In addition, the rates of occurrence, approaches to treatment, and the implications for social work practice are discussed.
Cross-Cultural Perspective of Schizophrenia
Diagnosis
Schizophrenia is defined as a disorder that lasts for at least six months and includes at least one month of active-phase symptoms of two or more of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000). Negative symptoms are described as a loss or decrease of normal functioning (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000). For example, a person unable to express emotion such as having a flattened affect or a person not speaking, unless prompted, as seen in normal speech are negative symptoms. Schizophrenia is often misunderstood and those diagnosed with this disorder are often given labels by society. The public attitude tends to characterize people suffering from schizophrenia as dangerous, unpredictable, and unreliable. The stereotypes and stigma associated with mental disorders are frequently the main obstacles preventing early and successful treatment. Particularly in the case of schizophrenia, the burden of stigma often leads to chronic social impairment (Jackowska, 2009).
Cross-Cultural Perspective Schizophrenia affects approximately 2.4 million Americans. Taking antipsychotic medication consistently is essential to the long-term treatment of this severe, disabling disorder and is obviously more effective than taking no medicine at all (National Institute of Mental Health, 2005). Although the medications alone are not sufficient to cure the disease, they are necessary to manage it. Rates of schizophrenia are usually comparable from country to country with about .5% to 1 percent of the population being affected (“Schizophrenia facts and statistics“, 2004). Approximately 1.1 percent of the population, age 18 and older, in the U.S. is diagnosed with schizophrenia (National Institute of Mental Health, 2010). The United States of America has a modernized healthcare system that is equipped to treat disorders such as schizophrenia. Although all Americans do not have access to health insurance there are many free clinics and medical assistance (Medicaid) available to those who qualify. How do people in developing countries manage who do not have the technology, resources, and treatments available to treat medical conditions and mental disorders such as schizophrenia? The countries of the Dominican Republic, Ethiopia, and Somalia were chosen to explore how these countries treat or not treat their people that are afflicted with this disorder.
The Dominican Republic The Dominican Republic is approximately 48,442 square kilometers and has a population of 8,562,541 (World Health Organization, 2008). The people treated in outpatient facilities are primarily diagnosed with affective disorders (32%) and schizophrenia (31%), and 21-50% received psychosocial interventions in the last year which are similar to crisis intervention and short stay admission in the U.S. (World Health Organization, 2008). As of 2008 the Dominican Republic did not have a mental health policy in place but with the assistance of the World Health Organization they are in the process of developing a comprehensive plan and policy (World Health Organization, 2008). Although there is no official policy, in 2006 the Dominican Republic updated their national standards for mental health care and Law No. 12-06 on mental health was enacted. The law states that every individual has the right to receive proper mental health care and the law also has safeguards in place to protect the rights of persons with mental disorders (World Health Organization, 2008). Psychotropic medicines are available in different types of facilities in this region, but in terms of affordability, a small percentage of the population (7%) has free access to vital psychotropic medicines (World Health Organization, 2008). For who have to pay for their medications out of pocket, the cost of antipsychotic medication is 12% and antidepressant medication is 10% of the minimum national wage (World Health Organization, 2008). The Dominican Republic has 56 outpatient mental health facilities and 9 psychiatric inpatient units within general hospitals. The region only has one mental hospital, one day treatment center, and one residential facility. The day treatment center treats 18 people per 100,000 of the population. Sixty percent of people in the day treatment facility are female and this figure does not include children and adolescents (World Health Organization, 2008). As far as the inpatient units available it was estimated from the research that 55% of the patients are female. The mental hospital is located in a rural area of the National District, has 150 beds, and 54% of patients are female and it does not treat children or adolescents (World Health Organization, 2008). In the mental hospital patients belong primarily to the following diagnostic groups: mood disorder (69%) and schizophrenia (21%). Affective disorders are the most common diagnosis in the mental hospital and a survey in 2005 indicated that 50% of the schizophrenic patients remain in their communities and a large number wander the streets (World Health Organization, 2008). The data shows that females represent the largest population in all mental health services in the region. The women being treated are between the ages of 18-65 due to very few services for children, adolescents, and individuals over the age of 65. The majority of the people with a diagnosis of schizophrenia are being treated in outpatient facilities (31%) and less are being treated in inpatient units (21%) (World Health Organization, 2008). In regards to race there was no data found to show the percentage by racial category of those being diagnosed and treated for schizophrenia. It can be deduced that the individuals with this disorder are mulattos and blacks because these groups represent the majority of the population in the Dominican Republic (World Health Organization, 2008). While exploring the link between socio-economic status and schizophrenia there was not much data found specific to the Dominican Republic. “Generally, epidemiological studies of mental disorders have repeatedly shown higher rates of schizophrenia at the lower end of the socio-economic continuum” (Link, Dohrenwend, & Skodol, 1986, p. 242). Therefore, the Dominican most likely also follows this trend. The rate of occurrence of schizophrenia and other non-affective psychoses in this region is estimated at 1% (World Health Organization, 2009). There was no data found in regards to sexual orientation and schizophrenia. Outpatient services in the region record and register data but it is not included in the national information system, therefore making it difficult to obtain all information needed. According to the World Health Organization (2008), finding information on mental health is a major weakness in this country. “Of all of the publications in the country in the last five years, few have been on mental health, and there are no publications on PubMed about the Dominican Republic’s mental health situation” (World Health Organization, 2008, p. 13).
Ethiopia
Ethiopia is approximately 1,104,000 square kilometers and its population as of 2004 was 72.42 million (World Health Organization, 2006). The people treated in outpatient facilities are primarily diagnosed with schizophrenia (41%), mood disorders (13%), and neurotic, stress related, and somatoform disorders made up 11% of diagnoses (World Health Organization, 2006). As of 2006 Ethiopia did not have a mental health policy however, a national mental health policy is currently under development (World Health Organization, 2006). In Ethiopia psychotropic medicines are not available in all of the primary health clinics. According to WHO (2006), half of the physician based primary health clinics have at least one type of psychotropic medicine available, whereas none of the clinics without physicians have them available. This causes difficulty in a country where physicians are scarce and primary care nurses are in charge of managing many of the clinics. Sixty-five percent of individuals who attend public mental health services have free access (at least 80%) to essential psychotropic medicines. For those who pay out of pocket the cost of antipsychotic medication is 3% of the daily minimum wage (World Health Organization, 2006). Ethiopia has 53 psychiatric outpatient mental health facilities, 6 inpatient facilities, 1 mental hospital, 1 residential facility in the country for the chronically mentally ill, and several other residential facilities (World Health Organization, 2006). In comparison to the Dominican Republic where the majority of users of the mental health facilities are female the exact opposite is the case in Ethiopia where the majority of users are male (World Health Organization, 2006). A study was conducted in 2002 in Butajira (rural Ethiopia) and the study showed that being male, under 35 years of age, unmarried, educated and living in an urban area were factors all associated with schizophrenia independently of each other. The risk of schizophrenia associated with being male was much higher in those aged 35 and over compared to those less than 35 years of age. The risk of schizophrenia among males was higher in those not married (never married, separated, divorced or widowed) compared to those who were married. The association of marital status with schizophrenia was also more prominent among those aged 35 years or over compared to those under 35. The link between schizophrenia and being unmarried was higher in urban than in rural areas. The study concluded that the socio-demographic correlates of schizophrenia in this rural population were similar to those described for the developed world (Debede, Alem, Hegash, Deyassa, & Beyero, 2004). The outpatient facilities treat 84 users per 100,000 of the population and 36% are female and 6% are children or adolescents. In the mental hospital patients belong primarily to the following diagnostic groups: mood disorder (25%) and schizophrenia (60%). The number of patients in the mental hospital in 2004 was 1,235 with 31% being female and 7% were children or adolescents. Overall the majority of treatment for schizophrenia is provided in outpatient facilities and individuals are given psychotropic medication. There is no information in the research that shows therapy or follow-up aftercare as part of the treatment plan (World Health Organization, 2006). In regards to race it is unknown, due to lack of data, as to what the percentage is by racial category of those being diagnosed and treated for schizophrenia. While exploring the link between socio-economic status and schizophrenia there was not much data found specific to Ethiopia. Since the country is a low-income group country (based on World Bank 2004 criteria) and with 85% of the population living in rural areas one can imply that many of the individuals diagnosed with schizophrenia are from a low socio-economic status. (World Health Organization, 2006). The rate of occurrence of schizophrenia and other non-affective psychoses in this region is estimated at 1% (World Health Organization, 2009). There was no data found in regards to sexual orientation and schizophrenia.

Mogadishu and South/Central Somalia Somalia is located in east Africa, bordering the Gulf of Aden on the north and the India Ocean, east of Ethiopia. Its ethnic groups include the African Bantu and Arab (15%) and the remaining (85%) are Somali. The estimated population is 9,118,773. Culturally, the Somali people are nomads and semi nomads and they rigidly follow the clan based traditional behaviors (World Health Organization, 2009). The people treated in outpatient facilities are primarily diagnosed with epilepsy (36%), schizophrenia (32%), neurosis (28.3%), and depression (1.6%) (World Health Organization, 2009). The rate of occurrence of schizophrenia and other non-affective psychoses in this region is estimated at 1% (World Health Organization, 2009). As of 2007 Somalia did not have a mental health policy however, a national mental health policy is currently under development. (World Health Organization, 2009). In Somalia psychotropic medicines are provided by the World Health Organization at no cost in all of the public health facilities (World Health Organization, 2009). According to WHO (2009), people who pay out of pocket for antipsychotic medication pay 5% and 2% for antidepressants of the minimum daily wages. Those who are registered in mental health outpatient facilities have free access to necessary psychotropic medicines. It was found that less than 20% of the patient population was registered and receiving these free medications. The majority of the patients turn to traditional methods for treatment before relying on a mental health facility (World Health Organization, 2009). The people of Somalia are known to practice traditional ways to treat mental illness. They use superstitious ways that were based on religious and cultural beliefs. For example, most Somali people believe that mental illnesses can only be treated with the assistance of the Koran and they do not believe that scientific medicine can treat the illness. Others believe that people who have depression or schizophrenia have special powers given by God and should be respected. Another belief is that they possess black magic or are evil (World Health Organization, 2009). Somalia has only 2 psychiatric outpatient mental health facilities and only 3 mental hospitals. There is no day treatment, community inpatient, or community residential facilities in this region (World Health Organization, 2009). In comparison to the Dominican Republic and Ethiopia they have fewer facilities to treat mental disorders and this most likely has to do with the reliance on traditional methods and beliefs in regards to treating mental illness. The outpatient facilities treated 1,094 patients in 2007 that comprised of 51% male and 49% female. Children and adolescents consisted of 22.6% of the patients and the rest were adults (World Health Organization, 2009). In regards to race it is unknown, due to lack of data, as to what the percentage is by racial category of those being diagnosed and treated for schizophrenia. The same is true for data regarding sexual orientation and socio-economic status. “There is no mental health reporting system in the country and the data collection system are poor and undependable” (World Health Organization, 2009, p. 14).
Implications for Social Work Practice It is essential for those practicing social work to have knowledge about mental disorders and to also be culturally competent by acknowledging that different cultures view mental illness differently, as in the case with the people of Somalia who hold very traditional beliefs (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000). Social workers assessing the symptoms of schizophrenia in socio-economic or cultural situations that are different from their own must be aware of these differences in order to treat the client effectively. An effective tool that may be helpful for social workers to use when working with clients of similar or different cultural backgrounds is the culturagram. The culturagram, (Congress, 1994; Congress, 1997) a family assessment instrument, was originally developed to assist social workers in understanding culturally diverse clients and their families. The culturagram helps the worker learn more about the family by asking a series of questions related to language spoken at home or in community, health beliefs, crisis events, holidays and special events, values about education and work, etc. There are 10 areas that are addressed and these are placed in a diagram format. After completing a culturagram the social worker should be able to better understand, assess needs, and plan for treatment for individuals and families (Congress, 2004). In addition to responsibility to clients and patients, social workers also have an ethical duty to follow the practices and policies of their employing agency (NASW, 1999). There is a fine line between the value of the social worker and of the profession and of those of an employer. The social worker has to continuously balance between these two forces and know that there will continue to be challenges for social workers in healthcare settings and beyond.

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