Prevalence and course of schizophrenia in a Chinese rural area.
ABSTRACT To assess the characteristics and factors affecting course of schizophrenia in a Chinese rural area.
An epidemiological investigation was conducted to identify all the patients with schizophrenia among 149 231 people in Xinjin County, Chengdu.
The total prevalence of schizophrenia was 4.13 per 1000 population. Males had an earlier mean age of onset (29.6 years) than females (32.3 years). Duration of illness before treatment and the total duration of illness were found to be significantly associated with level of remission. The status of treatment, family economy, housing, and families' care of patients had a significant effect on the clinical course of the illness.
Duration of illness before treatment may be an important predictor of course in schizophrenia. Early treatment for the patients may produce higher level of improvement in prognosis. Education intervention and community-based service are urgent priorities for these patients.
- SourceAvailable from: Jeffrey Dean Gage[Show abstract] [Hide abstract]
ABSTRACT: Migration imposes stress and may contribute to the incidence of mental illness among natives of mainland China living overseas. Both cultural norms and service inadequacies may act as barriers to accessing needed mental health services.Shanghai archives of psychiatry. 12/2013; 25(6):375-82.
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ABSTRACT: Introduction Transcultural studies suggest that the social outcome of schizophrenia might be better in developing countries than in industrialized ones. This study aims to check this hypothesis and attempted to identify prognostic indicators of schizophrenia among Tunisian patients. Methods This study included all the outpatients responding to DSM IV criteria of schizophrenia for at least five years, during the study period. The assessment tools were: an interview with the patients and their families, data from medical records and the Global Assessment of Functioning scale (GAF) applied for the premorbid period, at two years after onset, at five years, and during the interview (current assessment). The social outcome was assessed by marital and labour market status, social network, sexuality and the GAF score. The outcome was considered to be good, if the current GAF > 60, intermediate if GAF was between 31 and 60 and severe if GAF ≤ 30. The three prognostic subgroups were compared in order to look for prognostic indicators. Results Informed consent was obtained from 60 patients (85.7% of outpatients) and from 56 families. The sex-ratio was 4 (48 men/12 women), the mean age of patients was 39.3 years; the mean follow-up was 14.7 years ([5–45]). School level was six years primary school in the majority of cases, and the living conditions were poor in 48.3% of cases (n = 29). During the interview, only 21.6% (n = 13) of patients were married. The majority of patients, who were working before the first episode, had lost their job. 76.6% (n = 46) did not have any social contacts and only 23.3% (n = 14) had any sexual activity. Thus, the social outcome was good in 21% of patients, intermediate in 11.1% and severe in 67.9%. Most social indicators (GAF score, labour market status, social network) revealed a fairly similar progress: a significant decline between the premorbid period and two years after the onset. The course reached a plateau after two years. According to current GAF scores, outcome was good in 25% (n = 15) of cases, intermediate in 55% (n = 33) of them and severe in 20% (n = 12). Some indicators were found to be correlated with this outcome: patient related factors; late language development (correlated with intermediate prognosis [p = 0.03]); a comorbid axis II diagnosis (correlated with poorer outcome p = 0.04); a poor premorbid global functioning (higher premorbid GAF scores were correlated with a better outcome [p < 0.03]); family history related factors; consanguinity in parents (correlated with intermediate-severe prognosis [p = 0.04]); elderly father at birth (correlated with severe prognosis [p = 0.04]). Conclusion Even if these results are limited in their generalisation, this Tunisian sample argues that schizophrenia’s prognosis is not better in such a developing country.L Encéphale 06/2009; 35(3):234-240. · 0.60 Impact Factor
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ABSTRACT: This article describes the personal, societal, and economic burden attributable to schizophrenia in the People's Republic of China and highlights the potential for effective outpatient treatment to reduce this burden given recent changes in the Chinese health care system. The importance of effective antipsychotic therapy in reducing the burden of schizophrenia is also examined. Published research on the burden, disability, management, and economic costs of schizophrenia in the People's Republic of China was examined in the context of the larger body of global research. Research written in English or Chinese and published before June 2012 was identified using PubMed, CNKI, and Wanfang Med database searches. The contribution of effective antipsychotic therapy in reducing the risk for relapse and hospitalization and improving patients' functioning is described. Schizophrenia imposes a substantial burden on Chinese society, with indirect costs accounting for the majority of the total cost. Functional impairment is high, leading to lost wages and work impairment. In the People's Republic of China, schizophrenia is the most common diagnosis among hospitalized psychiatric patients. Ongoing changes in the Chinese health care system may reduce some barriers to effective relapse prevention in schizophrenia and potentially reduce hospitalizations. The use of antipsychotics for acute episodes and maintenance treatment has been shown to decrease symptom severity and reduce the risk for relapse and hospitalization. However, discontinuing antipsychotic medication appears common and is a strong predictor of relapse. Cost-effectiveness research in the People's Republic of China is needed to examine the potential gains from improved outpatient antipsychotic treatment. Schizophrenia is a very costly mental illness in terms of personal, economic, and societal burden, both in the People's Republic of China and globally. When treated effectively, patients tend to persist longer with antipsychotic treatment, have fewer costly relapses, and have improved functioning. Further research examining the long-term effects of reducing barriers to effective treatments on the societal burden of schizophrenia in the People's Republic of China is needed.ClinicoEconomics and Outcomes Research 01/2013; 5:407-18.
Prevalence and course of schizophrenia in a
Chinese rural area
Mao-Sheng Ran, Meng-Ze Xiang, Sheng-Xian Li, You-He Shan,
Ming-Sheng Huang, Si-Gan Li, Zhong-Ren Liu, Eric Yu-Hai Chen,
Cecilia Lai-Wan Chan
Chinese rural area.
schizophrenia among 149 231 people in Xinjin County, Chengdu.
The total prevalence of schizophrenia was 4.13 per 1000 population. Males had an
earlier mean age of onset (29.6 years) than females (32.3 years). Duration of illness before
treatment and the total duration of illness were found to be significantly associated with level
of remission. The status of treatment, family economy, housing, and families’ care of patients
had a significant effect on the clinical course of the illness.
Duration of illness before treatment may be an important predictor of course
in schizophrenia. Early treatment for the patients may produce higher level of improvement in
prognosis. Education intervention and community-based service are urgent priorities for
Chinese, epidemiology, rural area, schizophrenia.
To assess the characteristics and factors affecting course of schizophrenia in a
An epidemiological investigation was conducted to identify all the patients with
Australian and New Zealand Journal of Psychiatry 2003; 37:452–457
The characteristics of patients with schizophrenia in
rural China do need be explored as there about 63.8% of
the Chinese population lives in rural areas . Accord-
ing to a previous study , there are about 5.49 million
persons with schizophrenia in China. Among these
patients, 3.5 million patients live in rural areas. More-
over, the current condition of patients with schizo-
phrenia in rural China is unsatisfactory . Thus, the
study on these patients will be helpful for planning
mental health services, which are insufficient at present,
to accommodate them [3,4].
Clinical course in schizophrenia has been the subject
of extensive investigation throughout the last century.
A number of reports have indicated that gender, age at
onset, and treatment condition (e.g. maintenance treat-
ment) may influence the course of schizophrenia [5–7].
Moreover, culture can affect various aspects of the
illness process, including illness definition, help-seeking
behaviour, response to treatment, and post-treatment
adjustment . The course of schizophrenia appears to
be better in developing, than developed countries;
reasons for this are far from clear, nevertheless, it can
be safely assumed that culturally determined processes,
whether social or environmental, are partly responsible
[9,10]. However, although many studies of factors affect-
ing schizophrenia (e.g. gender, age at onset, housing)
Mao-Sheng Ran, Associate Professor (Correspondence); Meng-Ze Xiang,
Professor; You-He Shan, Professor; Ming-Sheng Huang, Professor
Institute of Mental Health, West China Hospital, West China Medical
School of Sichuan University, Chengdu, China
Sheng-Xian Li, Professor
Shashi City Veterans Psychiatric Hospital, Shashi City, China
Si-Gan Li, Associate Professor; Zhong-Ren Liu, Attending Doctor
Xinjin Mental Hospital, Chengdu, China
Eric Yu-Hai Chen, Associate Professor; Cecilia Lai-Wan Chan, Professor
(Correspondence address) Center of Suicide Research and Prevention,
The University of Hong Kong, Pokfulam Road, Hong Kong.
Received 2 July 2002; revised 21 March 2003; accepted 28 March 2003.
M.S. RAN, M.Z. XIANG, S.X. LI, Y.H. SHAN, M.S. HUANG, S.G. LI, Z.R. LIU, E.Y.H. CHEN, C.L.W. CHAN453
have been conducted in other countries [11–16], this
issue has been seldom touched in China.
The aims of this study were to assess the characteris-
tics of schizophrenia and related factors affecting it.
Methods are as previously described by Ran
population in the rural area of Xinjin county identified (framework
populations) was 235 546. The six townships (including 149 231 people
in the rural community, of whom 123 572 were aged over 15 years)
were randomly selected from all 14 townships of Xinjin County in the
south of Chengdu. There was not much in or out migration when the
investigation was conducted. An epidemiological investigation of all
the people was conducted in the six townships in October 1994. First,
the face-to-face interview was conducted with each head of household
(together with key informant method) for identifying potential cases of
mental disorder. The Psychoses Screening Schedule (PSS) was filled
in by means of interviewing the heads of all the households, and
discussion with village doctors and neighbourhoods comprising the
survey sample [17,18]. Second, when positive answers were obtained
for a subject on the screening procedures for psychosis, a comprehen-
sive general psychiatric interview was then completed with that subject
by a survey psychiatrist. All the patients who met the criteria of
schizophrenia of the Chinese Classification and Diagnostic Criteria
of Mental Disorder (CCMD-2-R) and the International Classification
of Disease (ICD-10) were included in the study.
. . Total
Widely used national epidemiological schedules and rating scales
were used to assess symptoms and social abilities. Standard instruments
including PSS, Present State Examination (PSE-9, Chinese translation),
the Psychotic Diagnosis and Record Schedule, and the Social Disability
Screening Schedule (SDSS) [17,18] were used. Family history was
obtained in a structured way. Age at onset refers to the age of the first
sign of psychotic behaviour. All the raters (15 psychiatrists) were
trained prior to investigation. The mean percentage agreement of all the
above instruments on the ratings for 10 patients ranged from 80.5% to
99.0%. Kappa values between pairs of investigators ranged from 0.7 to
All persons with positive results of PSS were assessed by the raters.
There were 510 patients with schizophrenia among the population
whose age was above 15 years. The number of males was 239 (46.9%),
and females was 271 (53.1%). The number of current-episode patients
(with psychotic symptoms at the time of the survey) was 367 cases, of
which the number of males was 173 (47.1%), and females was
194 (52.9%). For the 510 patients with schizophrenia, the patients’ age
ranged from 15 to 95 years (mean = 44.6, SD = 15.5), and the mean
duration of illness was 12.5 years (SD = 11.3). Among these patients,
there were 45 cases (8.8%) whose duration of illness was less than
1 year; and 357 cases (70.0%) whose duration of illness was more than
Overall, 143 of 510 patients (28.0%) had a family history of mental
illness (including psychosis, mental retardation, epilepsy, alcohol
dependence) in first- or second-degree relatives, and this prevalence
did not differ by gender (70 of 238 men (29.4%); 73 of 272 women
(26.8%) (p > 0.05)). Of all the patients, 108 (21.2%) were single,
327 (64.1%) were married, 40 (7.8%) were widowed and 35 (6.9%)
Mean age at onset (mean = 31.0, SD = 12.9). For 397 of 510 patients
(77.8%) onset was before the age of 40. The peak period of onset was
15–29 years for males and 20–39 years for females. Mean age at onset
among males (mean = 29.6, SD = 13.5) was significantly younger than
that among females (mean = 32.3, SD = 12.5) (
p < 0.05). Moreover, mean age at onset among all the patients who had
a positive family history of mental illness (mean = 29.0, SD = 12.3)
was significantly younger than that among all the patients who had a
negative family history of mental illness (mean = 31.8, SD = 13.2)
5.02, p < 0.05).
The total prevalence of schizophrenia among 123 572 people (over
15 years) was 4.13 per 1000. The current prevalence of patients with
schizophrenia (not recovery patients) was 2.97 per 1000. Meanwhile,
there were no significant differences in the total and current prevalence
between females (4.38 per 1000, and 3.12 per 1000) and males (3.88
per 1000, and 2.82 per 1000) (p > 0.05).
In Xinjin county, there was one mental hospital and many general
hospitals. Of the 510 patients with schizophrenia, 156 (30.6%) never
accepted any treatment, 30 (5.9%) were accepting antipsychotic drug
treatment, 8 (1.6%) were in the mental hospital, 118 (23.1%) had been
hospitalized at one time, 92 (18.0%) maintained irregular treatment for
less than 2 months, and 106 patients (20.8%) had only used Chinese
herbal medicine. Of all the patients with schizophrenia, 278 cases
(54.5%) had once consulted a traditional healer and accepted spiritual
treatment. There were more females (163 cases, 58.6%) accepting
spiritual treatment than males (115 cases, 41.4%) (
For 354 patients (69.4%) who once accepted treatments including
antipsychotic drugs, Chinese herbal medicine and spiritual healing,
the mean duration of psychosis before treatment was 3.6 months
(SD = 10.7 months). The first three agencies consulted by these
patients are shown in Table 1.
For the first consultations by patients, about two-fifths went to see
doctors at the mental hospital. The proportion of patients who went
to see the primary health workers including doctors of traditional
Chinese medicine in the village and general hospital was 32.8%. Of
510 patients, 38 (7.5%) had experienced suicidal thoughts or behav-
iour during their illness history.
Compared with the patients who accepted treatment in the first
contact, the proportion seeking treatment in the second and third
contacts significantly decreased to 67.0% and 27.4%, respectively
> 55, p < 0.001). Although the proportion of patients who accepted
treatment was decreased in the second and third contacts, the propor-
tion of patients who went to see a spiritual healer still maintained a
relatively high level (more than 37.1%).
= 7.4, p < 0.05).
454SCHIZOPHRENIA IN A CHINESE RURAL AREA
Families’ recognition of illness
Among 354 patients who once accepted the treatment, the first
symptom of the patients that caused their relatives to take them to seek
help were as follows: the change of the behavioural manner including
bizarre behaviour in speaking and other behaviours (268 cases, 75.7%),
violent, aggressive or suicidal behaviour (40 cases, 11.3%), change of
routine life including personal hygiene, sleeping and diet (24 cases,
6.8%), disabilities of social function at school, work unit, and home (14
cases, 3.9%) and complaints of physical discomfort or pain (8 cases,
2.3%). The results indicated that most families would not take the
patients to see a doctor unless the patients had severe behavioural
For the 354 treated patients, their relatives’ recognition of their
abnormal symptoms was as follows: 169 relatives (47.7%) did not
know what problem the patients had, 105 (29.7%) thought that some-
thing was wrong with the patients’ brain, 45 (12.7%) believed that the
patients thought too much, 28 (7.9%) insisted that the abnormal behav-
iour was caused by ghosts or gods and 7 (2.0%) believed that the
patients suffered from physical illness. The results indicated that most
relatives in the rural community had no knowledge of mental illness.
Factors affecting course
To examine the relation between course of the illness and other vari-
ables, patients were classified (at the point of assessment) as in com-
plete remission with no residual symptoms (125 cases, 24.5%), partial
remission of positive symptoms but with some remaining residual
positive or negative symptoms (68 cases, 13.4%), marked symptoms
(no remission of severe symptoms, 274 cases, 53.7%), and deteriorated
(43 cases, 8.4%).
Duration of the illness before treatment and duration of psychotic
symptoms were correlated significantly with the measure of clinical
course (p < 0.01). Age at onset and age at the investigation point were
not significantly associated with the level of remission (p > 0.05)
As shown in Table 3, treatment condition, family economic level,
housing situation and status of relatives’ care were significantly asso-
ciated with the clinical course of schizophrenia. There was no signifi-
cant difference of course between males and females among the
patients. The course in the patients who maintained regular medication
for more than 1 year was better than the other patients. The course in
the patients who once accepted medication and/or traditional treatment
was significantly better than that in the patients who accepted no
treatment at all. Meanwhile, there was no significant difference in the
clinical course between the patients who accepted medication irregu-
larly and the patients who accepted the traditional treatment
Moreover, the better economic condition of the patient, stable
housing and better care by the family were significantly related to
better remission of the illness. The results also showed that most of the
patients (92.4%) had stable living arrangements.
Patients’ work ability
Among all the patients with schizophrenia, the percentage who could
do full-time farm- or housework, part-time farm- or housework, or
could do nothing was 43.1% (220 cases), 38.1% (194 cases) and 18.8%
(96 cases), respectively. Among the 274 symptomatic patients, there
were 199 cases (72.6%) who could do full-time, or part-time farm- or
Of the total group of 510 patients with schizophrenia, there were
117 (22.9%) who had a negative influence on society by destroying
Table 1.The first three agencies consulted (first three contacts)
Table 2.Correlation of variables with level of remission of patients with schizophrenia
Duration of psychotic symptoms (pretreatment)
Age at onset of psychotic symptoms
Total duration of psychotic (prodromal) symptoms
Age at the investigation point
n Spearman’s correlation coefficient
*correlation is significant at the 0.01 level (2-tailed).
M.S. RAN, M.Z. XIANG, S.X. LI, Y.H. SHAN, M.S. HUANG, S.G. LI, Z.R. LIU, E.Y.H. CHEN, C.L.W. CHAN 455
property, injuring people or disturbing social order, and 6 (1.2%) who
caused severe disturbance (killing or arson) to society.
The prevalence of schizophrenia (4.13 per 1000) in
this study is similar to the prevalence of schizophrenia
(4.26 per 1000) in the 1982 epidemiological study of
12 districts in China (p < 0.05) . Moreover, there is
no significant difference between the prevalence of
males and females in this study. The results did not
correspond with the results of 12 districts in 1982, which
showed the prevalence of females was significantly
higher than that of males. This finding needs to be
The results of the study indicate that the male patients
had an earlier mean age of onset (29.6 years) than the
female patients (32.3 years) this was similar to that in a
number of previous studies [6,19–21]. Although the
gender effect on the course of illness had not been found
among all the patients with schizophrenia, the effect was
found among the patients who accepted no treatment .
Among patients who had never received any treatment,
females had a significantly better clinical course of the
illness than males (p < 0.05), which is consistent with a
few previous studies [15,22]. Except biological reasons
, this could be related to the fact that female patients
in Chinese rural area have been accepted better at home
than male patients, resulting in an apparent delayed age
at onset and a better course.
Patients with a positive family history of mental illness
had an early mean age of onset of illness than those with
a negative family history, which was consistent with the
study of Alda
. . This may reflect the vulner-
ability of the persons with family history. Moreover,
there is evidence indicating that patients with a family
history of psychosis improved more in 5 years follow-up
as compared with those without a family history .
However, the results of this study didn’t support this
There was evidence which indicated that there was
a potential impact of duration of untreated illness on
course, such as the time interval between symptom onset
and institution of neuroleptic treatment [14,24]. Early
neuroleptic treatment may enhance treatment response
and course in patients with schizophrenia [14,25,26].
The duration of psychosis before treatment may also be
an important predictor of course in first-episode patients
Table 3.Factors influencing clinical course of schizophrenia
χ χ χ χ
Family history of mental illness
Brief or irregular treatment
Family economic status
High (> mean)
Low (< mean)
Poor housing or homeless
Family care state
4.4 4.5> 0.05
4.62.2 > 0.05
156 9.68.375.7 6.4d
26847.0 < 0.001
33.3 34.9< 0.001
10.2, df = 3, p = 0.016; ac.
33.3, df = 3, p < 0.001.
9.2, df = 3, p = 0.027; bc
0.7, df = 3, p = 0.880; bd
39.4, df = 3, p < 0.001;
456SCHIZOPHRENIA IN A CHINESE RURAL AREA
with schizophrenia . The results of the present study
also indicate that the duration of illness prior to treat-
ment and the total duration of illness might be important
predictors of course in rural patients with schizophrenia.
Delay in drug treatment may be associated with a sig-
nificantly worse course and shorter duration of untreated
illness prior to the initial acute episode which may be
significantly associated with favourable course. Thus,
how to diagnose and treat these patients in an early
stage of illness should be emphasized in Chinese rural
The results of this study indicate that 75.5% patients
were assessed as having symptoms, this was consistent
with previous studies [11,28]. Moreover, the relationship
between treatment condition and clinical course was also
found in this study. The overall course in the samples of
this study was gloomy, and the course in untreated
patients was negative . The course was better in the
patients with any kind of treatment (e.g. medication or
traditional methods) than those without any treatment.
The clinical course of patients in the regular treatment
group was the most favourable, which has also been
indicated by many other studies [7,14,29]. Meanwhile, it
is interesting to note that complete remission occurred in
a similar proportion (about 30%) among patients with
different treatments except the patients without treat-
ment at all (remission < 10%). The results also indicated
that there was a substantial subgroup of patients with
schizophrenia with a good prognosis , and the
importance of the treatment should be emphasized .
The better courses appeared to be related to the greater
availability of housing alternatives [16,31]. Patients with
unstable housing were more likely to be literally home-
less, highly symptomatic, and rehospitalized during
follow-up. The results of the present study also sup-
ported this issue. Poor family economic and housing
situations were correlated with the poor clinical course.
Housing instability remains an important signifier of
risk. The reason might be that patients with schizo-
phrenia in Chinese rural areas who had unstable housing
situations usually lived in a poor family, experienced
multiple psychosocial problems, had few supports, and
exhibited dangerous behaviours and medication non-
compliance . So, besides the treatment, especially
medication, stable housing is also crucial for successful
community service for these patients.
Although remission depended greatly on early treat-
ment and good treatment compliance , this study
indicated the situation was serious as the fact that only
37.8% patients initially consulted a psychiatrist in a
mental hospital, and 30.6% patients never accepted treat-
ment at all. The reason for the delay of help-seeking
behaviour might be associated with the following:
1. Family recognition on mental illness was poor: the
family usually thought that it was undesirable to talk
with psychotic patients, and they saw psychotic illness
as a stigma; family members might tolerate psycho-
pathology to a greater extent and seek medical service
for their ill relatives only after severe behaviour symp-
toms; for the treatment, 90.0% of patients’ families who
seek spiritual treatment said that they had to turn to seek
the Gods’ help when the patients did not get recovery
after the first-treatment; and they didn’t know the neces-
sity of long-term treatment.
2. The attitudes of family members towards the
patients was poor: family attitude was to let the patients
live as normal if they had no serious disruptive behav-
iours, or to lock up or even restrain them at home if they
had severe disruptive behaviours .
The results of this study indicated that poor clinical
course was associated with the insufficient family care
or maltreatment. Therefore, it is crucial to educate the
public and patients’ families about the knowledge of
mental illness and how to care for the patients. Family
intervention may be an effective approach of improving
treatment compliance and should be an important part of
community mental health care in rural China .
Meanwhile, it was very important to train the primary
health workers (general doctors and village doctors) to
conduct community mental health care in rural China as
one-third of patients went to see them first.
The limitation of the present study is the assessment
outcome data based on a prevalence sample (with wide
variation in duration of illness). However, this study
recruited a representative sample including all the patients
with schizophrenia in a rural community. As mentioned
in our previous study , it is unavoidable that true
cases may be missed using the screening instrument.
This study was supported by grant from the China
Medical Board of New York, Inc. (CMB, Grant No:
92-557). We thank Professor Julian Leff for advice on
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