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Schizophrenia around the world
Schizophrenia Around the World Ming
T. Twang
ROM THE TIME when the concept of schizophrenia was first described by Kraepelin and later by Bleuler, its meaning has varied from country to country, and even from center to center within the same country. This confusion about the meaning of the illness of course makes various aspects of research into schizophrenia very difficult. As part of a program by the World Health Organization to develop firm knowledge on the etiology and pathogenesis of mental disorders, a research program was developed on the diagnosis, classification, statistics, and epidemiology of mental disorders. ’ The first annual international seminar sponsored by this program concentrated on schizophrenia, and the International Pilot Study on Schizophrenia (IPSS),” of which I was one of the collaborating investigators, was initiated in 1965. The primary tasks outlined when the study began were to devise standard research instruments and procedures for case finding and for the assessment of the degree of psychiatric impairment in schizophrenia; the demonstration that comparable cases of schizophrenia disorders can be identified in different cultures; and the description of course taken by cases in the period after their firm diagnosis. In order to carry out these tasks, nine field centers were selected in nine countries throughout the world: Aarhus, Denmark; Agra, India; Cali, Columbia; Ibadan, Nigeria; London, England; Moscow, USSR; Taipei, Taiwan; Washington, U.S.A.; and Prague, Czechoslovakia. These centers were chosen to represent major contrasting cultures of the world at different levels of social and industrial development; yet the centers would be capable of detecting most of the likely and early cases of schizophrenia in a population of approximately one-half to one million people. The pilot study was divided into three phases: phase 1, preparatory phase; phase II, identification of cases; and phase III, follow-up phase. The results of the first two phases have been published in the Report of the International Pilot Study qf’ Schizophrenia, Vol. Z; volume II will contain results of the follow-up phase. During phase I (July 1966-March 1968) the nine field research centers were established, the adequacy of the catchment area of each center was assessed, cases were registered, and research instruments were chosen, translated, and adapted to the local language of each center. Also, a standard application of research instruments and procedures was established; each center interviewed 26 functional psyhcotics aged 15-44 with a history of illness for less than 5 years. Sixteen
F
From rhe Department of Psychiatry. College of Medicine. C’niversity of Iowa and the Psychopathic Hospital. Iowa City, Iowa. Ming T. Tsuang, M.D., Ph.D.: Professor of Psychiatv, Department of Psychiatry. College of Medicine. University of Iowa and StaffPsychiatrist. Psychopathic Hospiral, Iowa Ciry, Ioti’a. This paper is a transcript of a speech given at the Annual Scientific Meeting of the Iowa Ps?,chiatrir Society and Department of Psychiatry. University of Iowa. November 1974. Reprinf requests should be addressed to Ming T. Tsuang. M.D.. Psychopathic Hospiral. 100 dYewton Road. Iowa City, Iowa 52242. lc?1976 bv Grune & Stratton, Inc. Comprehensive Psychiatry, Vol.
17.
No.
3
(May/JuneJ.
1976
477
470
MING T. TSUANG
of the 26 were interviewed simultaneously or consecutively by 2 interviewers from each center, and 10 received a single interview. Based on the rating of these interviews and filmed interviews circulated among the field research centers, the research instruments were modified for use in phase II (April 1968-May 1969). One of the instruments used for phase II was the Present State Examination Schedule (PSE) that originated in the Medical Research Council, Social Psychiatry Research Unit, Maudsley Hospital, University of London. The PSE was translated into eight other languages from English: Hindi, Danish, Spanish, Yoruba, Chinese, Russian, French, and Czech. The PSE included 235 items for rating patients’ reported symptoms experienced during the past month, and 125 items for rating behavior observed during the interview. The areas assessed were interest, concentration, somatic symptoms, irritability, mood, obsessional symptoms, derealization, hallucinations, delusions, behavior in interview, observed affect, and speech and rapport. The Psychiatric History Schedule (PH) was another research instrument used in phase II. The PH of 204 items was designed to be administered by either psychiatrist, other medical officers, or social workers; the information was obtained from either patients or other informants. The areas included in the PH were history of present and past episode of illness, treatment, premorbid personality traits, significant events in life story, psychologic adjustment to work and psychosexual adjustment, history of use of alcohol and drugs, and legal history. The Social Description Schedule (SD) used contained 156 items including social functioning before and during illness, description of residence and household, education, work, marriage and children, patient’s childhood setting, his sibship and parents, religious activities, social and leisure activities. Upon completion of the examination, patients were assessed according to a standard Diagnostic Assessment Schedule (DA) which was made up of six openended questions requiring a summary of findings, a statement of diagnosis according to the system used in each center, and a check list of international classification of disease categories. Also included were scales for rating the prognosis. The identification of cases in phase II required each center to identify at least 125 nonorganic psychotics and 10 neurotic depressives, male and female, aged 15-44 who had resided in the catchment area for at least 6 months or more. Cases were excluded when the severe psychotic symptoms in the episode were probably continuously present for more than 3 years or when there was a total hospitalization of 2 years or more in the last 5 years, including readmissions. From all centers, 1202 cases (550 males and 652 females) were studied; a balanced sex and age distribution was achieved for the sample as a whole. Of the 1202 cases, 811 received clinical diagnosis of schizophrenia, with each center having at least 60 schizophrenic patients, except Aarhus with only 53. The largest single diagnostic subgroup for the 811 schizophrenics was paranoid (318); paranoids were the largest group in all centers, except for Agra, Cali, and Moscow. Paranoid schizophrenics accounted for 72% of all schizophrenics in London, 53% in Aarhus and Washington, and 40% or more in Ibadan and Taipei. The second largest subgroup was schizo-affective schizophrenia (107), most strongly represented in Agra, Ibadan, and Prague. There were 86 hebephrenics (30 in Taipei and 20 in Cali) and 56 catatonic (21 in Agra, 13 in Cali, and 10 in Ibadan). For Moscow, the largest single subgroups was other schizophrenia
SCHIZOPHRENIA
AROUND
THE WORLD
479
(44%), and for Agra, the largest individual group was unspecified schizophrenia (28%). Aside from the centers’ original clinical diagnosis, the 8 1I schizophrenics were classified using two other methods: a computer diagnosis of schizophrenia (Catego S), based on the presence of a few important symptoms traditionally regarded as being associated with typical schizophrenia, and a cluster analysis that gives equal weight to all symptoms to select those clusters which have significant numbers of patients with clinical diagnosis of schizophrenia. Of the 8 11 schizophrenics, 563 received a computer classification of schizophrenia, and 550 were in the 3 McKeon clusters which contain a statistically significantly higher number of schizophrenics than could be expected by chance. There were 306 patients who were classified schizophrenic according to all 3 systems, the clinical classification, the computer classification, and the cluster analysis. These 306 schizophrenics make up a concordant group of schizophrenics. There were concordant schizophrenics in all nine centers. The concordant group composed 61% of all the schizophrenics in Cali, 55% in London, 47% in Ibadan, 41% in Taipei, 38% in Aarhus, 30% in Agra, 25% in Prague, 19% in Moscow, and 16% in Washington. Despite the difference between centers, there was a significant number of concordant cases in each of the nine centers to allow comparison between centers by diagnostic subgroups. Paranoids were the largest single subgroup for all centers; 152 of the concordant group were paranoid, which is 47.1% of all the paranoids in the study. The 152 paranoids in the condordant group were distributed among all centers with the following breakdown: London, 40; Ibadan, 27: Taipei, 18; Cali, 15; Prague, 15; Aarhus, 14; Washington, 11; Agra, 8; and Moscow, 4. The second largest subgroup for the concordant schizophrenics was hebephrenic schizophrenia; there were 37 hebephrenics, which is 43.0% of all the hebephrenics in the study. The hebephrenics by center were: Cali, 11; Taipei, 11; Aarhus, 5; Ibadan, 5; and London, 5. Other diagnostic categories in the concordant group are acute schizophrenic episode (30), schizo-affective disorder (29), unspecified schizophrenia (20), catatonic (17), other schizophrenia (12), simple schizophrenia (6), residual schizophrenia (2), and latent schizophrenia (1). Aside from comparison among centers, the concordant group can be compared generally with other groups within the pilot study. One comparison group is the discrepant group, those cases clinically diagnosed as schizophrenic but who were not classified schizophrenic according to Catego S or the cluster analysis. When the concordant group and the discrepant group are compared in terms of 27 psychopathologic characteristics, there is a significant difference seen between the two groups. The concordant group scored higher for the characteristics of delusions, hallucinations, and flatness of affect, while the discrepant group scored higher on depressive symptomatology. For lack of insight, the concordant group scored about 97% and the discrepant group 55%; this was the highest scoring characteristic for both groups. The scores for auditory hallucinations were 60% concordant, zero for discrepant. For experiences of control the concordant group scored 50% compared with 5% for the discrepant group. The concordant group scored 50% on flatness, and the discrepant group was about 20%. For the characteristic depressed-elated mood, the discrepant group scored about 10% higher than the concordant group. The concordant group may also be compared with all psychotically depressed
480
MING
T. TWANG
patients within the study (involutional melancholia, manic-depressive illness, depressed type, and psychotic depressive reaction). On the basis of the same 27 characteristics, the concordant group is even less similar to the psychotically depressed group. The most marked differences were seen in the following characteristics: lack of insight (97% concordant versus 45% depression), auditory hallucinations (60% concordant versus 8% depression), experiences of control (50% concordant versus 5% depression), flatness (50% concordant versus 11% depression), cooperation difficulties (47% concordant versus 20% depression). The depression group scored higher than the concordant group for the following characteristics: affect-laden thoughts (39% depression versus 23% concordant), depressed-elated (38% depression versus 15% concordant), neurasthenic complaints (28% depression versus 17% concordant), and psychophysical disorders (30% depression versus 12% concordant). From the work completed in phases I and II of the International Pilot Study of Schizophrenia, three major conclusions can be seen. First, it has been possible to carry out a large scale international psychiatric study requiring the coordination and collaboration of psychiatrists and other mental health workers from different theoretical psychiatric backgrounds and from widely separated countries with different cultures and socioeconomic conditions. Secondly, similar groups of schizophrenics can be identified in every one of the nine countries involved in the study. Finally, it is in fact possible to develop valid and reliable research instruments for practical use in international psychiatric studies. The results of phase III of the study to be published in a second volume will include the l-year and 2-year follow-up evaluation of patients. These results should be very helpful for investigating the relationship of diagnosis, symptomatology, and sociocultural factors on initial evaluation to course and social outcome. In Iowa we are also undertaking a comprehensive study of schizophrenia as well as mania and depression3 This research starts with 525 patients who were selected from inpatients consecutively admitted to Iowa Psychopathic Hospital between 1934 and 1944. They were selected according to specific research criteria (Feighner et al., 1972)4 for schizophrenia (200), bipolar affective disorder (loo), and unipolar affective disorder (225). The main goals of the proposed research are: (1) to accomplish a 35-year follow-up of these 525 index patients (probands), and (2) to personally interview all living first-degree relatives residing in the state, or within 300 miles of Iowa City, or in the near vicinity of any proband. For the purpose of obtaining comprehensive epidemiologic data, a structured interview form (Iowa Structured Psychiatric Interview) was designed specifically for this project. The interview of both probands and their relatives is being conducted without knowledge of the probands’ research diagnosis (blind interview). In order to achieve the maximum effect of the blind interview and to obtain a baseline for comparison, a stratified random sample of 160 nonpsychiatric control subjects and their first degree relatives will also be interviewed blindly. The control subjects were selected from patients admitted to the University’s General Hospital for appendectomy and for herniorrhaphy during the same period. The purpose of this project, known locally as “Iowa 500,” is to obtain objective data to shed light on our understanding of schizophrenia and affective disorders, their diagnostic validity, clinical features, course and outcome, heterogeneity, life
SCHIZOPHRENIA
AROUND
481
THE WORLD
histories, related illness, and characteristics of familial association. The major significance of this project is the potential for delineating homogenous subgroups within the general rubric of affective disorders and schizophrenia for future biologic and psychosocial studies. ACKNOWLEDGMENT This paper is partially based on the data and experience obtained during participation of the author in the International Pilot Study of Schizophrenia, a project sponsored by the World Health Organization, and funded by the World Health Organization, the National Institute of Mental Health, and the participating field research centers. The following were the collaborating investigators on this study. At Headquarters in WHO. Geneva. Switzerland-Dr. N. Sartorius (principal investigator), Dr. T. Y. Lin (former principal investigator), E. M. Brooke, Dr. F. Engelsmann, Dr. G. Ginsburg, M. Kimura, Dr. A. Richman. and Dr. R. Shapiro. In the field research centers-Aarhus, Denmark: Dr. E. Stromgren (chief collaborating investigator [cci]), Dr. A. Bertelsen, Dr. M. Fischer, Dr. C. Flach, and Dr. N. Juel-Nielsen; Agra, India: Dr. K. (1. Dube (cci) and Dr. B. S. Yadav; Cali, Colombia: Dr. C. Leon (cci), Dr. G. Calderon. and Dr. E. Zambrano; Ibadan, Nigeria: Dr. T. A. Lambo (cci) and Dr. T. Asuni; London, England: Dr. J. K. Wing (cci), Dr. J. Birley, and Dr. J. P. Leff; Moscow, USSR: Dr. R. A. Nadzarov (cci) and Dr. N. M. Zharikov: Prague, Czechoslovakia: Dr. 1. Hanzlicek (cci) and Dr. C. Skoda; Taipei. Taiwan: Dr. C. C:. Chen (cci) and Dr. M. T. Tsuang; Washington. D.C., U.S.A.: Dr. .I S. Strauss (cci). Dr. L.. C. Wynne. Dr. M. W. T. Carpenter, Jr.. and Dr. John J. Bartko. REFERENCES I. Biological
Research
in Schizophrenia:
Report of a WHO Scientific Group. World Health Organization Report Series, No. 450, Geneva, 1970 2. Report of the International Pilot Study of Schizophrenia, vol I. World Health Organization, Geneva. 1973
3. Clancy J. Tsuang MT. Norton B. et al: The Iowa 500: A comprehensive study of mania, depression and schizophrenia. J Iowa Med Sot Sept 1974, pp 394.-398 4. Feighner JP, Robins E. Guze SD, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57 63. I972
T. Twang
ROM THE TIME when the concept of schizophrenia was first described by Kraepelin and later by Bleuler, its meaning has varied from country to country, and even from center to center within the same country. This confusion about the meaning of the illness of course makes various aspects of research into schizophrenia very difficult. As part of a program by the World Health Organization to develop firm knowledge on the etiology and pathogenesis of mental disorders, a research program was developed on the diagnosis, classification, statistics, and epidemiology of mental disorders. ’ The first annual international seminar sponsored by this program concentrated on schizophrenia, and the International Pilot Study on Schizophrenia (IPSS),” of which I was one of the collaborating investigators, was initiated in 1965. The primary tasks outlined when the study began were to devise standard research instruments and procedures for case finding and for the assessment of the degree of psychiatric impairment in schizophrenia; the demonstration that comparable cases of schizophrenia disorders can be identified in different cultures; and the description of course taken by cases in the period after their firm diagnosis. In order to carry out these tasks, nine field centers were selected in nine countries throughout the world: Aarhus, Denmark; Agra, India; Cali, Columbia; Ibadan, Nigeria; London, England; Moscow, USSR; Taipei, Taiwan; Washington, U.S.A.; and Prague, Czechoslovakia. These centers were chosen to represent major contrasting cultures of the world at different levels of social and industrial development; yet the centers would be capable of detecting most of the likely and early cases of schizophrenia in a population of approximately one-half to one million people. The pilot study was divided into three phases: phase 1, preparatory phase; phase II, identification of cases; and phase III, follow-up phase. The results of the first two phases have been published in the Report of the International Pilot Study qf’ Schizophrenia, Vol. Z; volume II will contain results of the follow-up phase. During phase I (July 1966-March 1968) the nine field research centers were established, the adequacy of the catchment area of each center was assessed, cases were registered, and research instruments were chosen, translated, and adapted to the local language of each center. Also, a standard application of research instruments and procedures was established; each center interviewed 26 functional psyhcotics aged 15-44 with a history of illness for less than 5 years. Sixteen
F
From rhe Department of Psychiatry. College of Medicine. C’niversity of Iowa and the Psychopathic Hospital. Iowa City, Iowa. Ming T. Tsuang, M.D., Ph.D.: Professor of Psychiatv, Department of Psychiatry. College of Medicine. University of Iowa and StaffPsychiatrist. Psychopathic Hospiral, Iowa Ciry, Ioti’a. This paper is a transcript of a speech given at the Annual Scientific Meeting of the Iowa Ps?,chiatrir Society and Department of Psychiatry. University of Iowa. November 1974. Reprinf requests should be addressed to Ming T. Tsuang. M.D.. Psychopathic Hospiral. 100 dYewton Road. Iowa City, Iowa 52242. lc?1976 bv Grune & Stratton, Inc. Comprehensive Psychiatry, Vol.
17.
No.
3
(May/JuneJ.
1976
477
470
MING T. TSUANG
of the 26 were interviewed simultaneously or consecutively by 2 interviewers from each center, and 10 received a single interview. Based on the rating of these interviews and filmed interviews circulated among the field research centers, the research instruments were modified for use in phase II (April 1968-May 1969). One of the instruments used for phase II was the Present State Examination Schedule (PSE) that originated in the Medical Research Council, Social Psychiatry Research Unit, Maudsley Hospital, University of London. The PSE was translated into eight other languages from English: Hindi, Danish, Spanish, Yoruba, Chinese, Russian, French, and Czech. The PSE included 235 items for rating patients’ reported symptoms experienced during the past month, and 125 items for rating behavior observed during the interview. The areas assessed were interest, concentration, somatic symptoms, irritability, mood, obsessional symptoms, derealization, hallucinations, delusions, behavior in interview, observed affect, and speech and rapport. The Psychiatric History Schedule (PH) was another research instrument used in phase II. The PH of 204 items was designed to be administered by either psychiatrist, other medical officers, or social workers; the information was obtained from either patients or other informants. The areas included in the PH were history of present and past episode of illness, treatment, premorbid personality traits, significant events in life story, psychologic adjustment to work and psychosexual adjustment, history of use of alcohol and drugs, and legal history. The Social Description Schedule (SD) used contained 156 items including social functioning before and during illness, description of residence and household, education, work, marriage and children, patient’s childhood setting, his sibship and parents, religious activities, social and leisure activities. Upon completion of the examination, patients were assessed according to a standard Diagnostic Assessment Schedule (DA) which was made up of six openended questions requiring a summary of findings, a statement of diagnosis according to the system used in each center, and a check list of international classification of disease categories. Also included were scales for rating the prognosis. The identification of cases in phase II required each center to identify at least 125 nonorganic psychotics and 10 neurotic depressives, male and female, aged 15-44 who had resided in the catchment area for at least 6 months or more. Cases were excluded when the severe psychotic symptoms in the episode were probably continuously present for more than 3 years or when there was a total hospitalization of 2 years or more in the last 5 years, including readmissions. From all centers, 1202 cases (550 males and 652 females) were studied; a balanced sex and age distribution was achieved for the sample as a whole. Of the 1202 cases, 811 received clinical diagnosis of schizophrenia, with each center having at least 60 schizophrenic patients, except Aarhus with only 53. The largest single diagnostic subgroup for the 811 schizophrenics was paranoid (318); paranoids were the largest group in all centers, except for Agra, Cali, and Moscow. Paranoid schizophrenics accounted for 72% of all schizophrenics in London, 53% in Aarhus and Washington, and 40% or more in Ibadan and Taipei. The second largest subgroup was schizo-affective schizophrenia (107), most strongly represented in Agra, Ibadan, and Prague. There were 86 hebephrenics (30 in Taipei and 20 in Cali) and 56 catatonic (21 in Agra, 13 in Cali, and 10 in Ibadan). For Moscow, the largest single subgroups was other schizophrenia
SCHIZOPHRENIA
AROUND
THE WORLD
479
(44%), and for Agra, the largest individual group was unspecified schizophrenia (28%). Aside from the centers’ original clinical diagnosis, the 8 1I schizophrenics were classified using two other methods: a computer diagnosis of schizophrenia (Catego S), based on the presence of a few important symptoms traditionally regarded as being associated with typical schizophrenia, and a cluster analysis that gives equal weight to all symptoms to select those clusters which have significant numbers of patients with clinical diagnosis of schizophrenia. Of the 8 11 schizophrenics, 563 received a computer classification of schizophrenia, and 550 were in the 3 McKeon clusters which contain a statistically significantly higher number of schizophrenics than could be expected by chance. There were 306 patients who were classified schizophrenic according to all 3 systems, the clinical classification, the computer classification, and the cluster analysis. These 306 schizophrenics make up a concordant group of schizophrenics. There were concordant schizophrenics in all nine centers. The concordant group composed 61% of all the schizophrenics in Cali, 55% in London, 47% in Ibadan, 41% in Taipei, 38% in Aarhus, 30% in Agra, 25% in Prague, 19% in Moscow, and 16% in Washington. Despite the difference between centers, there was a significant number of concordant cases in each of the nine centers to allow comparison between centers by diagnostic subgroups. Paranoids were the largest single subgroup for all centers; 152 of the concordant group were paranoid, which is 47.1% of all the paranoids in the study. The 152 paranoids in the condordant group were distributed among all centers with the following breakdown: London, 40; Ibadan, 27: Taipei, 18; Cali, 15; Prague, 15; Aarhus, 14; Washington, 11; Agra, 8; and Moscow, 4. The second largest subgroup for the concordant schizophrenics was hebephrenic schizophrenia; there were 37 hebephrenics, which is 43.0% of all the hebephrenics in the study. The hebephrenics by center were: Cali, 11; Taipei, 11; Aarhus, 5; Ibadan, 5; and London, 5. Other diagnostic categories in the concordant group are acute schizophrenic episode (30), schizo-affective disorder (29), unspecified schizophrenia (20), catatonic (17), other schizophrenia (12), simple schizophrenia (6), residual schizophrenia (2), and latent schizophrenia (1). Aside from comparison among centers, the concordant group can be compared generally with other groups within the pilot study. One comparison group is the discrepant group, those cases clinically diagnosed as schizophrenic but who were not classified schizophrenic according to Catego S or the cluster analysis. When the concordant group and the discrepant group are compared in terms of 27 psychopathologic characteristics, there is a significant difference seen between the two groups. The concordant group scored higher for the characteristics of delusions, hallucinations, and flatness of affect, while the discrepant group scored higher on depressive symptomatology. For lack of insight, the concordant group scored about 97% and the discrepant group 55%; this was the highest scoring characteristic for both groups. The scores for auditory hallucinations were 60% concordant, zero for discrepant. For experiences of control the concordant group scored 50% compared with 5% for the discrepant group. The concordant group scored 50% on flatness, and the discrepant group was about 20%. For the characteristic depressed-elated mood, the discrepant group scored about 10% higher than the concordant group. The concordant group may also be compared with all psychotically depressed
480
MING
T. TWANG
patients within the study (involutional melancholia, manic-depressive illness, depressed type, and psychotic depressive reaction). On the basis of the same 27 characteristics, the concordant group is even less similar to the psychotically depressed group. The most marked differences were seen in the following characteristics: lack of insight (97% concordant versus 45% depression), auditory hallucinations (60% concordant versus 8% depression), experiences of control (50% concordant versus 5% depression), flatness (50% concordant versus 11% depression), cooperation difficulties (47% concordant versus 20% depression). The depression group scored higher than the concordant group for the following characteristics: affect-laden thoughts (39% depression versus 23% concordant), depressed-elated (38% depression versus 15% concordant), neurasthenic complaints (28% depression versus 17% concordant), and psychophysical disorders (30% depression versus 12% concordant). From the work completed in phases I and II of the International Pilot Study of Schizophrenia, three major conclusions can be seen. First, it has been possible to carry out a large scale international psychiatric study requiring the coordination and collaboration of psychiatrists and other mental health workers from different theoretical psychiatric backgrounds and from widely separated countries with different cultures and socioeconomic conditions. Secondly, similar groups of schizophrenics can be identified in every one of the nine countries involved in the study. Finally, it is in fact possible to develop valid and reliable research instruments for practical use in international psychiatric studies. The results of phase III of the study to be published in a second volume will include the l-year and 2-year follow-up evaluation of patients. These results should be very helpful for investigating the relationship of diagnosis, symptomatology, and sociocultural factors on initial evaluation to course and social outcome. In Iowa we are also undertaking a comprehensive study of schizophrenia as well as mania and depression3 This research starts with 525 patients who were selected from inpatients consecutively admitted to Iowa Psychopathic Hospital between 1934 and 1944. They were selected according to specific research criteria (Feighner et al., 1972)4 for schizophrenia (200), bipolar affective disorder (loo), and unipolar affective disorder (225). The main goals of the proposed research are: (1) to accomplish a 35-year follow-up of these 525 index patients (probands), and (2) to personally interview all living first-degree relatives residing in the state, or within 300 miles of Iowa City, or in the near vicinity of any proband. For the purpose of obtaining comprehensive epidemiologic data, a structured interview form (Iowa Structured Psychiatric Interview) was designed specifically for this project. The interview of both probands and their relatives is being conducted without knowledge of the probands’ research diagnosis (blind interview). In order to achieve the maximum effect of the blind interview and to obtain a baseline for comparison, a stratified random sample of 160 nonpsychiatric control subjects and their first degree relatives will also be interviewed blindly. The control subjects were selected from patients admitted to the University’s General Hospital for appendectomy and for herniorrhaphy during the same period. The purpose of this project, known locally as “Iowa 500,” is to obtain objective data to shed light on our understanding of schizophrenia and affective disorders, their diagnostic validity, clinical features, course and outcome, heterogeneity, life
SCHIZOPHRENIA
AROUND
481
THE WORLD
histories, related illness, and characteristics of familial association. The major significance of this project is the potential for delineating homogenous subgroups within the general rubric of affective disorders and schizophrenia for future biologic and psychosocial studies. ACKNOWLEDGMENT This paper is partially based on the data and experience obtained during participation of the author in the International Pilot Study of Schizophrenia, a project sponsored by the World Health Organization, and funded by the World Health Organization, the National Institute of Mental Health, and the participating field research centers. The following were the collaborating investigators on this study. At Headquarters in WHO. Geneva. Switzerland-Dr. N. Sartorius (principal investigator), Dr. T. Y. Lin (former principal investigator), E. M. Brooke, Dr. F. Engelsmann, Dr. G. Ginsburg, M. Kimura, Dr. A. Richman. and Dr. R. Shapiro. In the field research centers-Aarhus, Denmark: Dr. E. Stromgren (chief collaborating investigator [cci]), Dr. A. Bertelsen, Dr. M. Fischer, Dr. C. Flach, and Dr. N. Juel-Nielsen; Agra, India: Dr. K. (1. Dube (cci) and Dr. B. S. Yadav; Cali, Colombia: Dr. C. Leon (cci), Dr. G. Calderon. and Dr. E. Zambrano; Ibadan, Nigeria: Dr. T. A. Lambo (cci) and Dr. T. Asuni; London, England: Dr. J. K. Wing (cci), Dr. J. Birley, and Dr. J. P. Leff; Moscow, USSR: Dr. R. A. Nadzarov (cci) and Dr. N. M. Zharikov: Prague, Czechoslovakia: Dr. 1. Hanzlicek (cci) and Dr. C. Skoda; Taipei. Taiwan: Dr. C. C:. Chen (cci) and Dr. M. T. Tsuang; Washington. D.C., U.S.A.: Dr. .I S. Strauss (cci). Dr. L.. C. Wynne. Dr. M. W. T. Carpenter, Jr.. and Dr. John J. Bartko. REFERENCES I. Biological
Research
in Schizophrenia:
Report of a WHO Scientific Group. World Health Organization Report Series, No. 450, Geneva, 1970 2. Report of the International Pilot Study of Schizophrenia, vol I. World Health Organization, Geneva. 1973
3. Clancy J. Tsuang MT. Norton B. et al: The Iowa 500: A comprehensive study of mania, depression and schizophrenia. J Iowa Med Sot Sept 1974, pp 394.-398 4. Feighner JP, Robins E. Guze SD, et al: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57 63. I972