- Email: [email protected]
Unmedicated patients with schizophrenia in economically underdeveloped areas of China
Asian Journal of Psychiatry 47 (2020) 101865
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Unmedicated patients with schizophrenia in economically underdeveloped areas of China
T
Ying Weia,b,1, Wen Lic,d,1, Lan Zhanga,*, Ju-Hong Zhua, Xiu-Jie Zhua, Xiu-Yun Maa, Qiang-Li Donga, Wen-Li Zhaoe, Wei-Min Pane, Xia Jiange, Gabor S. Ungvarif,g, Chee H. Ngh, Yu-Tao Xianga,d,** a
Department of Psychiatry, Lanzhou University Second Hospital, Gansu province, China Lanzhou Centers for Disease Control, Gansu province, China c Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macao d Center for Cognition and Brain Sciences, University of Macau, Macao e Gansu Centers for Disease Control, Gansu province, China f Division of Psychiatry, School of Medicine, University of Western Australia, Perth, Australia g University of Notre Dame Australia, Fremantle, Australia h Department of Psychiatry, The Melbourne Clinic and St Vincent's Hospital, The University of Melbourne, Melbourne, Australia b
A R T I C LE I N FO
A B S T R A C T
Keywords: Schizophrenia Treatment Rural Urban Economic level
Objectives: Untreated schizophrenia commonly leads to poor prognosis. The medication treatment rate of schizophrenia patients in economically underdeveloped areas of China has not been well-studied. This study aimed to examine the pattern of unmedicated schizophrenia patients in economically underdeveloped rural and urban areas of China. Method: A total of 4240 schizophrenia patients in Lanzhou (1720 rural and 2520 urban patients) registered in the community mental-health service system in Lanzhou, Gansu province were included. Their socio-demographic and clinical characteristics including medication treatment status were collected and analyzed. Results: The proportion of unmedicated schizophrenia patients was 22.5% (n = 953) in the whole sample, with 32.3% (556/1720) in rural and 15.8% (397/2520) in urban patients (X2=161.1, P < 0.001). Multiple logistic regression analyses revealed that unmedicated schizophrenia patients in rural area were more likely to be older (OR=1.02, 95%CI: 1.01–1.03), male (OR=1.35, 95%CI: 1.07–1.71), unmarried (OR=0.71, 95%CI: 0.55-0.91), and have lower educational level (OR=0.39, 95%CI: 0.24-0.65), longer illness duration (OR=1.01, 95%CI: 1.00–1.02) and less frequent admissions (OR=0.46, 95%CI: 0.38-0.54). In contrast, unmedicated patients in urban area were more likely to be older (OR=1.01, 95%CI: 1.00–1.02), unmarried (OR=0.77, 95%CI: 0.610.98), employed (OR=2.38, 95%CI: 1.87–3.04), and have lower educational level (OR=0.49, 95%CI: 0.370.65), better financial status (OR=0.60, 95%CI: 0.48-0.76) and less frequent admissions (OR=0.81, 95%CI: 0.75-0.87). Conclusions: The rate of unmedicated schizophrenia patients is high in economically underdeveloped areas of China, particularly in rural areas. Effective policies and measures should be implemented urgently to improve the treatment rate in this population.
1. Introduction Early intervention with appropriate medications can improve the prognosis of schizophrenia (Cohen et al., 2008; Higuchi et al., 2019). Compared to schizophrenia patients treated with psychotropic
medications, unmedicated schizophrenia patients usually have poor long-term outcomes, such as higher suicide risk, more severe psychotic symptoms, worse social functioning (Kurihara et al., 2005; Li et al., 2018; Padmavathi et al., 1998; Ran et al., 2001, 2007) and poorer physical condition (De Hert et al., 2011; Wasnik et al., 2019). Longer
⁎
Corresponding author. Corresponding author at: 3/F, Building E12, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macao. E-mail addresses: [email protected] (L. Zhang), [email protected] (Y.-T. Xiang). 1 These authors contributed equally to the work. ⁎⁎
https://doi.org/10.1016/j.ajp.2019.101865 Received 4 October 2019; Received in revised form 1 November 2019; Accepted 1 November 2019 1876-2018/ © 2019 Elsevier B.V. All rights reserved.
Asian Journal of Psychiatry 47 (2020) 101865
Y. Wei, et al.
between August 2011 and May 2019. Following other studies (Wang et al., 2015; Wu et al., 2004) and the recommendation of local health authorities, unmedicated patients were defined as those who did not receive any psychotropic medications (i.e., antipsychotics, antidepressants, mood stabilizer, and benzodiazepines) since the onset of their illness.
duration of untreated psychosis is also associated with worse prognosis (Marshall et al., 2005; Penttilä et al., 2014; Perkins et al., 2005). In developing countries, such as in China, the treatment rate of schizophrenia patients remains relatively low (Padmavathi et al., 1998; Phillips et al., 2009; Ran et al., 2001; Srinivasan et al., 2001). For instance, one study (Phillips et al., 2009) found that 27.6% of Chinese patients with schizophrenia or related disorders never sought help from mental health professionals, while 12% had received treatment in nonpsychiatric services, such as provided by general physicians and Chinese medicine practitioners. A longitudinal study in China found that the proportion of treatment-naïve patients with schizophrenia gradually decreased from 30.6% in 1994 to 20.4% in 2008 (Ran et al., 2015a). Several demographic and clinical factors are associated with the use of medication in schizophrenia patients, such as higher education level, greater access to mental health professionals, higher financial status, less economic burden of treatment and better social support system (Wang et al., 2000; World Health Organization, 2005). However, most studies had a small sample size and were conducted in economically developed areas of China, and therefore, their findings may not be applicable to economically underdeveloped areas (Yang, 2019). In China, most patients with schizophrenia and other severe mental illness usually live in the community, partly supported by the recently developed community-based psychiatric service system. Due to limited health resources, however, schizophrenia patients in economically underdeveloped areas usually have little or no access to mental health services (Xiang et al., 2018). Understanding the pattern of unmedicated schizophrenia patients can help develop appropriate policies and treatment strategies for this vulnerable group. To date, there are no large-scale studies that specifically examined the medication treatment rate of schizophrenia patients in economically underdeveloped areas of China. Therefore, we investigated the pattern of unmedicated schizophrenia patients who were living in economically underdeveloped areas of China, and also explored its demographic and clinical correlates. Due to the differences in financial level, social support and health resources, patients living in both rural and urban areas were studied. We hypothesized that the proportion of unmedicated schizophrenia patients in rural areas would be higher than in urban areas.
2.3. Statistical analysis Data analyses were performed with SPSS 24.0 for Windows (SPSS Inc., Chicago, IL, USA). The comparisons between medicated and unmedicated patients regarding demographic and clinical characteristics were conducted in rural and urban groups separately, using chi-square test, two independent samples t test, Mann-Whitney U test and Fisher’s exact test as appropriate. The Kolmogorov–Smirnov test was used to examine the normal distribution of the continuous variables. Multiple logistic regression analysis with the “enter” method (i.e., all independent variables are entered simultaneously) was conducted to examine the demographic and clinical variables independently associated with unmedicated status in rural and urban groups separately. Considering the large sample size, all demographic and clinical variables were entered as independent variables, while unmedicated status was entered as the dependent variable. The significance level was set as 0.05 (two-tailed). 3. Results A total of 4240 community-dwelling patients with schizophrenia were included, with 1720 (40.6%) rural and 2520 (59.4%) urban residents. The proportion of unmedicated schizophrenia patients was 22.5% (n = 953) in the whole sample, with 32.3% (556/1720) in rural and 15.8% (397/2520) in urban patients (X2=161.1, P < 0.001). Table 1 shows the comparisons of socio-demographic and clinical characteristics between medicated and unmedicated patients by rural and urban areas. In rural areas, unmedicated patients were more likely to be older, male gender, unmarried, and had lower education level, less frequent admissions and longer duration of illness. In urban areas, unmedicated patients were more likely to be older, employed, and had lower education level, better financial status and less frequent admissions. As shown in Table 2, multiple logistic regression analyses revealed that older age (OR = 1.02, 95%CI: 1.01–1.03), male gender (OR = 1.35, 95%CI: 1.07–1.71), unmarried marital status (OR = 0.71, 95%CI: 0.55-0.91), lower education level (OR = 0.39, 95%CI: 0.240.65), longer illness duration (OR = 1.01, 95%CI: 1.00–1.02) and less frequent admissions (OR = 0.46, 95%CI: 0.38-0.54) were significantly and positively associated with unmedicated status in rural areas. In contrast, unmedicated status was significantly associated with older age (OR = 1.01, 95%CI: 1.00–1.02), unmarried marital status (OR = 0.77, 95%CI: 0.61-0.98), employed status (OR = 2.38, 95%CI: 1.87–3.04), lower education level (OR = 0.49, 95%CI: 0.37-0.65), better financial status (OR = 0.60, 95%CI: 0.48-0.76) and less frequent admissions (OR = 0.81, 95%CI: 0.75-0.87) in patients in rural areas. These variables accounted for 18.1% and 11.7% of the variance of unmedicated status in rural and urban areas, respectively.
2. Method 2.1. Patients and study site This cross-sectional study examined the demographic and clinical features of schizophrenia patients registered in the community mentalhealth service system (CMHSS) in Lanzhou, Gansu province. Lanzhou is the capital city of Gansu Province which is the most economically underdeveloped province in China and has around 3.6 million permanent residents (Municipal people’s government in Lanzhou, 2018). Those who were diagnosed with schizophrenia according to the ICD-10 criteria (World Health Organization, 1992) in public psychiatric hospitals were registered in the CMHSS, and were included in the study. There were no exclusion criteria. The Clinical Research Ethics Committee of the Gansu Centers for Disease Control, Gansu province, China approved the study, and in line with the local ethical standards and regulations, written informed consent was not required if data were collected only by a review of the CMHSS.
4. Discussion To the best of our knowledge, this was the first study in China to exclusively examine the medication treatment rate of schizophrenia patients in both economically underdeveloped rural and urban areas. We found that 22.5% of community-dwelling patients with schizophrenia in Lanzhou did not receive psychotropic medications. Gansu province is the most economically underdeveloped area in China (Yang, 2019), therefore, there is a shortage of mental health services compared to other areas (Zhao et al., 2017; Zhu and Wan, 2012), which is
2.2. Assessments Patients’ socio-demographic and clinical data, including age, gender, marital status, residence (rural or urban areas), educational level, employment status, family history of psychiatric disorders, financial status, duration of illness, number of hospitalizations, and treatment status, were retrieved from the CMHSS covering the period 2
Asian Journal of Psychiatry 47 (2020) 101865
Y. Wei, et al.
Table 1 Sociodemographic and clinical characteristics of medicated and unmedicated schizophrenia patients in economically underdeveloped rural and urban areas of China. Variable
Rural areas
Male gender Married Higher education# Employed Family history of psychiatric disorders Poor financial status*
Age (years) Illness duration (years) Number of hospitalizations
Urban areas
Medication-free (n = 556)
Medication-treated (n = 1164)
Statistics
N 304 296 22 501 30
% 54.7 53.2 4.0 90.1 5.4
N 568 686 132 1032 46
% 48.8 58.9 11.3 88.7 4.0
X2 5.2 4.9 25.1 0.8 1.8
df 1 1 1 1 1
431
77.5
855
73.5
3.2
1
Mean 52.4 20.4 0.2
SD 13.4 13.9 0.6
Mean 47.6 15.9 0.9
SD 13.1 11.0 1.5
Z −6.9 −6.0 −12.1
Medication-free (n = 397)
Medication-treated (n = 2123)
Statistics
P 0.023 0.026 < 0.001 0.367 0.173
N 226 175 68 150 27
% 56.9 44.1 17.1 37.8 6.8
N 1167 898 673 412 101
% 55.0 42.3 31.7 19.4 4.8
X2 0.5 0.4 34.2 65.1 2.8
df 1 1 1 1 1
P 0.472 0.510 < 0.001 < 0.001 0.089
0.070
229
57.7
1,494
70.4
24.9
1
< 0.001
P < 0.001 < 0.001 < 0.001
Mean 53.0 20.6 0.9
SD 13.5 13.0 1.5
Mean 49.6 19.3 1.7
SD 12.3 11.5 2.5
Z −5.0 −1.3 −8.2
P < 0.001 0.171 < 0.001
Bolded values: < 0.05; #senior middle school or above; *per capita annual income less than the current local poverty line; abbreviations: SD: standard deviation.
hospitalizations was negatively associated with the likelihood of unmedicated status in this study. More frequent hospitalizations could help patients and their families understand the importance of medication treatment, which could, therefore, reduce the likelihood of ceasing treatment. The relationship between gender and medication treatment has been controversial. Some studies found that untreated schizophrenia patients were more likely to be women (Hou et al., 2018; Wu et al., 2004), while others did not find any gender difference (Padmavathi et al., 1998; Ran et al., 2015a). This study found that unmedicated patients in rural areas were more likely to be men. A multicenter study in China found that male patients had more negative attitude toward antipsychotic treatments (Zhou et al., 2016); in addition, a lower marital rate was found in male schizophrenia patients (Thara and Srinivasan, 1997), especially in rural area of China (Ran et al., 2017; Yang et al., 2012), both of which could reduce the likelihood of helpseeking and being medicated. Longer illness duration was positively associated with unmedicated status in rural patients. With prolonged illness duration, patients were more likely to have negative attitudes towards medication treatment (Zhou et al., 2016), be unmarried (Ran et al., 2017), and have poorer insight and more severe cognitive impairment (Altamura et al., 2015; Carroll et al., 1999), all of which could reduce the acceptance of medication treatment (Bitter et al., 2015; Choudhury et al., 2009; Lambert et al., 2010). This study found that unmedicated patients in urban areas were more likely to be employed and have a better financial status. The possible explanation is that compared to their rural counterparts, urban schizophrenia patients were more likely to work (Yang et al., 2013) and conceal their illness (Loganathan and Murthy, 2008). Consequently, urban patients may often refuse medication treatment in order to reduce the risk of medication-induced side effects. The strengths of this study included the large sample size and inclusion of both rural and urban areas. However, several limitations need to be addressed. First, due to cross-sectional design, the causal relationship between unmedicated status and other variables could not be examined. Second, due to logistic reasons, only Gansu province was included, which limits the generalization of the findings to other economically underdeveloped areas of China. Third, some variables related to treatment status, such as prescription and doses of psychotropic medications, the severity of psychotic symptoms and social support, were not available in the CMHSS. Fourth, no standardized instruments were utilized to measure psychotic symptoms. In conclusion, the rate of unmedicated schizophrenia patients living in the community in Lanzhou is high, particularly in rural areas. Considering the negative health outcomes of unmedicated status, in order to improve the treatment rate in in economically underdeveloped
Table 2 Basic-demographic and clinical characteristics of unmedicated patients in rural and urban areas of China. Rural areas
Urban areas
Variables
OR
95%CI
P
OR
95%CI
P
Age Male gender Married Higher education# Employed Family history of psychiatric disorders Poor financial status* Illness duration (years) Number of hospitalizations
1.02 1.35 0.71 0.39 0.97 1.36
1.01-1.03 1.07-1.71 0.55-0.91 0.24-0.65 0.68-1.40 0.81-2.27
< 0.001 0.011 0.007 < 0.001 0.902 0.232
1.01 1.19 0.77 0.49 2.38 1.33
1.00-1.02 0.94-1.50 0.61-0.98 0.37-0.65 1.87-3.04 0.84-2.11
< 0.001 0.133 0.040 < 0.001 < 0.001 0.214
1.10 1.01
0.85-1.42 1.00-1.02
0.461 0.007
0.60 1.00
0.48-0.76 0.99-1.01
< 0.001 0.480
0.46
0.38-0.54
< 0.001
0.81
0.75-0.87
< 0.001
Bolded values: P < 0.05; #Senior middle school or above; *per capita annual income less than the currently local poverty line; Abbreviations: CI: confidential interval; OR: odds ratio.
probably the major reason for the high rate of unmedicated schizophrenia patients. Schizophrenia patients in rural areas had a higher rate of unmedicated status, which is consistent with previous findings (Hou et al., 2018; Wang et al., 2015; Wu et al., 2004). The mental health resources in rural areas are inadequate compared to in urban areas (Xiang et al., 2018), with rural patients having less access to health education (Phillips, 2001) and lower awareness of the importance of medication treatment of psychiatric disorders (Liu, 2016). Furthermore, rural patients often face discrimination (Loganathan and Murthy, 2008), and as a result, are less likely to seek help from psychiatric professionals (Ran et al., 2015b; Wang et al., 2000). All these factors may contribute to the low medication treatment rate in rural patients. Several socio-demographic factors were significantly associated with unmedicated status in both rural and urban patients. Similar to earlier findings, unmedicated patients were more likely to be older (Padmavathi et al., 1998; Ran et al., 2015a, 2007), less educated (Padmavathi et al., 1998), and unmarried (Ran et al., 2015a; Thara and Srinivasan, 1997). Patients who were older and less educated were more likely to refuse treatment (Hoge et al., 1990; Wang et al., 2000) due to insufficient understanding of the importance of maintenance treatment (Liu, 2016). Married status was usually associated with better social support (Ran et al., 2017), which could improve the rate of medication treatment in schizophrenia. The number of psychiatric 3
Asian Journal of Psychiatry 47 (2020) 101865
Y. Wei, et al.
areas of China, accessible primary mental health services need to be established and mental health education on the importance of pharmacotherapy for schizophrenia should be conducted (Halbreich et al., 2019; Huang, 2011; Lin and Woo, 2018). In addition, effective policies should be implemented urgently (Hill et al., 2019).
China: comparisons within and between rural and urban areas. J. Clin. Psychiatry 79. Huang, Y.-q., 2011. Status quo and challenge of mental health in China. [in Chinese]. Chin. J.Health Policy 5–9. Kurihara, T., Kato, M., Reverger, R., Tirta, I.G.R., Kashima, H., 2005. Never-treated patients with schizophrenia in the developing country of Bali. Schizophr. Res. 79, 307–313. Lambert, M., Conus, P., Cotton, S., Robinson, J., McGorry, P.D., Schimmelmann, B.G., 2010. Prevalence, predictors, and consequences of long-term refusal of antipsychotic treatment in first-episode psychosis. J. Clin. Psychopharmacol. 30, 565–572. Li, A., Huang, X., Zhu, T., 2018. A systematic analysis of online broadcasts of suicidality in China. Asia-pacific Psychiatry 10, e12302. Lin, T.Y., Woo, B.K.P., 2018. Social media as an educational platform against stigma. Asia-pacific Psychiatry 10, e12320. Liu, H., 2016. Analysis on Implementing Situation and Degree of Satisfaction About Basic Public Health Services of Gansu Province in 2014 (in Chinese). Lanzhou University. Loganathan, S., Murthy, S.R., 2008. Experiences of stigma and discrimination endured by people suffering from schizophrenia. Indian J. Psychiatry 50, 39–46. Marshall, M., Lewis, S., Lockwood, A., Drake, R., Jones, P., Croudace, T., 2005. Association between duration of untreated psychosis and outcome in cohorts of firstepisode patients: a systematic review. Arch. Gen. Psychiatry 62, 975–983. Municipal people’s government in Lanzhou, 2018. The Population Division [in Chinese]. http://www.lanzhou.gov.cn/col/col7/index.html?authkey=gj2f1. Padmavathi, R., Rajkumar, S., Srinivasan, T.N., 1998. Schizophrenic patients who were never treated–a study in an Indian urban community. Psychol. Med. 28, 1113–1117. Penttilä, M., Jääskeläinen, E., Hirvonen, N., Isohanni, M., Miettunen, J., 2014. Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. Br. J. Psychiatry 205, 88–94. Perkins, D.O., Gu, H., Boteva, K., Lieberman, J.A., 2005. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am. J. Psychiatry 162, 1785–1804. Phillips, M.R., 2001. Schizophrenia in China. Dialogues Clin. Neurosci. 3, 112–119. Phillips, M.R., Zhang, J., Shi, Q., Song, Z., Ding, Z., Pang, S., Li, X., Zhang, Y., Wang, Z., 2009. Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey. Lancet 373, 2041–2053. Ran, M.-S., Weng, X., Chan, C.L.-W., Chen, E.Y.-H., Tang, C.-P., Lin, F.-R., Mao, W.-J., Hu, S.-H., Huang, Y.-Q., Xiang, M.-Z., 2015a. Different outcomes of never-treated and treated patients with schizophrenia: 14-year follow-up study in rural China. Br. J. Psychiatry 207, 495–500. Ran, M., Xiang, M., Huang, M., Shan, Y., 2001. Natural course of schizophrenia: 2-year follow-up study in a rural Chinese community. Br. J. Psychiatry 178, 154–158. Ran, M.S., Chan, C.L., Ng, S.M., Guo, L.T., Xiang, M.Z., 2015b. The effectiveness of psychoeducational family intervention for patients with schizophrenia in a 14-year follow-up study in a Chinese rural area. Psychol. Med. 45, 2197–2204. Ran, M.S., Chen, E.Y., Conwell, Y., Chan, C.L., Yip, P.S., Xiang, M.Z., Caine, E.D., 2007. Mortality in people with schizophrenia in rural China: 10-year cohort study. Br. J. Psychiatry 190, 237–242. Ran, M.S., Wong, Y.I., Yang, S.Y., Ho, P.S., Mao, W.J., Li, J., Chan, C.L., 2017. Marriage and outcomes of people with schizophrenia in rural China: 14-year follow-up study. Schizophr. Res. 182, 49–54. Srinivasan, T.N., Rajkumar, S., Padmavathi, R., 2001. Initiating care for untreated schizophrenia patients and results of one year follow-up. Int. J. Soc. Psychiatry 47, 73–80. Thara, R., Srinivasan, T.N., 1997. Outcome of marriage in schizophrenia. Soc. Psychiatry Psychiatr. Epidemiol. 32, 416–420. Wang, H., Song, Y., Yu, B., Yu, S., 2015. Investigation on treatment status of schizophrenia in Mudanjiang City(in Chinese). Journal of Clinical Medical 2, 4696–4698. Wang, P.S., Gilman, S.E., Guardino, M., Christiana, J.M., Morselli, P.L., Mickelson, K., Kessler, R.C., 2000. Initiation of and adherence to treatment for mental disorders: examination of patient advocate group members in 11 countries. Med. Care 926–936. Wasnik, V., Khess, C.R.J., Munda, S., Bijali, S., 2019. Serum prolactin level and its correlation with psychopathology in drug free/drug naive schizophrenia a case control study. Asian J. Psychiatr. 39, 1–5. World Health Organization, 1992. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Geneva. World Health Organization, 2005. Improving access and use of psychotropic medicines. Mental Health Policy and Service Guidance Package. Wu, M., Zhou, L., Li, H., Guo, L., Cha, Y., 2004. Current situation of treatment of rural schizophrenic patients (in Chinese). Chin. J. Clin. Rehab. 8, 3642. Xiang, Y.-T., Ng, C.H., Yu, X., Wang, G., 2018. Rethinking progress and challenges of mental health care in China. World Psychiatry 17, 231–232. Yang, L.H., Phillips, M.R., Li, X., Yu, G., Zhang, J., Shi, Q., Song, Z., Ding, Z., Pang, S., Susser, E., 2013. Employment outcome for people with schizophrenia in rural v. Urban China: population-based study. Br. J. Psychiatry 203, 272–279. Yang, Q., 2019. The formulation and implementation of Gansu Provincial government strategic management under the background of "one Belt and one Road" (in Chinese). Fujian Zhiliang Guanli 225. Yang, X., Attane, I., Li, S., Zhang, Q., 2012. On same-sex sexual behaviors among male bachelors in rural china: evidence from a female shortage context. Am. J. Mens Health 6, 108–119. Zhao, W., Pan, W., Ge, P., Jiang, X., Li, J., Xue, L., Wu, Z., Yao, L., 2017. Analysis of mental health service resources in Gansu Province (in Chinese). Disease Control Prev. Bull. 32, 19–22. Zhou, J., Xiang, Y.T., Li, Q., Zhu, X., Li, W., Ungvari, G.S., Ng, C.H., Ongur, D., Wang, X., 2016. Gender differences in attitudes towards antipsychotic medications in patients with schizophrenia. Psychiatry Res. 245, 276–281. Zhu, C., Wan, G., 2012. Rising inequality in China and the move to a balanced economy. China World Econ. 20, 83–104.
Ethical standards The Clinical Research Ethics Committee of the Gansu Centers for Disease Control, Gansu province, China approved the study, and in line with the local ethical standards and regulations, written informed consent was not required if data were collected only by a review of the community mental-health service system (CMHSS) in Lanzhou, Gansu province. We report this study in strict accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Availability of data and materials The Clinical Research Ethics Committee of the Gansu Centers for Disease Control, Gansu province, China that approved the study prohibits the authors from making the research data set publicly available. Readers and all interested researchers may contact Dr. Lan Zhang (Email address: [email protected]) for details. Dr. Zhang could apply to the Clinical Research Ethics Committee of the Gansu Centers for Disease Control for the release of the data. Financial disclosure None. Declaration of Competing Interest All authors declare no conflicts of interest concerning this article. Acknowledgements The authors are grateful to all patients and clinicians involved in this study. References Altamura, A.C., Serati, M., Buoli, M., 2015. Is duration of illness really influencing outcome in major psychoses? Nord. J. Psychiatry 69, 403–417. Bitter, I., Feher, L., Tenyi, T., Czobor, P., 2015. Treatment adherence and insight in schizophrenia. Psychiatria Hungarica 30, 18–26. Carroll, A., Fattah, S., Clyde, Z., Coffey, I., Owens, D.G.C., Johnstone, E.C., 1999. Correlates of insight and insight change in schizophrenia. Schizophr. Res. 35, 247–253. Choudhury, S., Khess, C.R., Bhattacharyya, R., Sanyal, D., 2009. Insight in schizophrenia and its association with executive functions. Indian J. Psychol. Med. 31, 71–76. Cohen, A., Patel, V., Thara, R., Gureje, O., 2008. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr. Bull. 34, 229–244. De Hert, M., Correll, C.U., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I., Detraux, J., Gautam, S., Möller, H.-J., Ndetei, D.M., Newcomer, J.W., Uwakwe, R., Leucht, S., 2011. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10, 52–77. Halbreich, U., Schulze, T., Botbol, M., Javed, A., Kallivayalil, R.A., Ghuloum, S., Baron, D., Moreira Almeida, A., Musalek, M., Fung, W.L.A., Sharma, A., Tasman, A., Christodoulou, N., Kasper, S., Ivbijaro, G., 2019. Partnerships for interdisciplinary collaborative global well-being. Asia-Pacif. Psychiatry 11, e12366. Higuchi, T., Ishigooka, J., Iyo, M., Yeh, C.B., Ebenezer, E.G., Liang, K.Y., Lee, J.S., Lee, S.Y., Lin, S.K., Yoon, B.H., Nakamura, M., Hagi, K., Sato, T., 2019. Lurasidone in the treatment of schizophrenia: results of a double-blind, placebo-controlled trial in Asian patients. Asia-Pacif. Psychiatry 11, e12352. Hill, H., Killaspy, H., Ramachandran, P., Ng, R.M.K., Bulman, N., Harvey, C., 2019. A structured review of psychiatric rehabilitation for individuals living with severe mental illness within three regions of the Asia-Pacific: implications for practice and policy. Asia-Pacif. Psychiatry 11, e12349. Hoge, S.K., Appelbaum, P.S., Lawlor, T., Beck, J.C., Litman, R., Greer, A., Gutheil, T.G., Kaplan, E., 1990. A prospective, multicenter study of patients’ refusal of antipsychotic medication. JAMA Psychiatry 47, 949–956. Hou, C.L., Chen, M.Y., Cai, M.Y., Chen, Z.L., Cai, S.B., Xiao, Y.N., Jia, F.J., 2018. Antipsychotic-free status in community-dwelling patients with schizophrenia in
4
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Unmedicated patients with schizophrenia in economically underdeveloped areas of China
T
Ying Weia,b,1, Wen Lic,d,1, Lan Zhanga,*, Ju-Hong Zhua, Xiu-Jie Zhua, Xiu-Yun Maa, Qiang-Li Donga, Wen-Li Zhaoe, Wei-Min Pane, Xia Jiange, Gabor S. Ungvarif,g, Chee H. Ngh, Yu-Tao Xianga,d,** a
Department of Psychiatry, Lanzhou University Second Hospital, Gansu province, China Lanzhou Centers for Disease Control, Gansu province, China c Unit of Psychiatry, Institute of Translational Medicine, Faculty of Health Sciences, University of Macau, Macao d Center for Cognition and Brain Sciences, University of Macau, Macao e Gansu Centers for Disease Control, Gansu province, China f Division of Psychiatry, School of Medicine, University of Western Australia, Perth, Australia g University of Notre Dame Australia, Fremantle, Australia h Department of Psychiatry, The Melbourne Clinic and St Vincent's Hospital, The University of Melbourne, Melbourne, Australia b
A R T I C LE I N FO
A B S T R A C T
Keywords: Schizophrenia Treatment Rural Urban Economic level
Objectives: Untreated schizophrenia commonly leads to poor prognosis. The medication treatment rate of schizophrenia patients in economically underdeveloped areas of China has not been well-studied. This study aimed to examine the pattern of unmedicated schizophrenia patients in economically underdeveloped rural and urban areas of China. Method: A total of 4240 schizophrenia patients in Lanzhou (1720 rural and 2520 urban patients) registered in the community mental-health service system in Lanzhou, Gansu province were included. Their socio-demographic and clinical characteristics including medication treatment status were collected and analyzed. Results: The proportion of unmedicated schizophrenia patients was 22.5% (n = 953) in the whole sample, with 32.3% (556/1720) in rural and 15.8% (397/2520) in urban patients (X2=161.1, P < 0.001). Multiple logistic regression analyses revealed that unmedicated schizophrenia patients in rural area were more likely to be older (OR=1.02, 95%CI: 1.01–1.03), male (OR=1.35, 95%CI: 1.07–1.71), unmarried (OR=0.71, 95%CI: 0.55-0.91), and have lower educational level (OR=0.39, 95%CI: 0.24-0.65), longer illness duration (OR=1.01, 95%CI: 1.00–1.02) and less frequent admissions (OR=0.46, 95%CI: 0.38-0.54). In contrast, unmedicated patients in urban area were more likely to be older (OR=1.01, 95%CI: 1.00–1.02), unmarried (OR=0.77, 95%CI: 0.610.98), employed (OR=2.38, 95%CI: 1.87–3.04), and have lower educational level (OR=0.49, 95%CI: 0.370.65), better financial status (OR=0.60, 95%CI: 0.48-0.76) and less frequent admissions (OR=0.81, 95%CI: 0.75-0.87). Conclusions: The rate of unmedicated schizophrenia patients is high in economically underdeveloped areas of China, particularly in rural areas. Effective policies and measures should be implemented urgently to improve the treatment rate in this population.
1. Introduction Early intervention with appropriate medications can improve the prognosis of schizophrenia (Cohen et al., 2008; Higuchi et al., 2019). Compared to schizophrenia patients treated with psychotropic
medications, unmedicated schizophrenia patients usually have poor long-term outcomes, such as higher suicide risk, more severe psychotic symptoms, worse social functioning (Kurihara et al., 2005; Li et al., 2018; Padmavathi et al., 1998; Ran et al., 2001, 2007) and poorer physical condition (De Hert et al., 2011; Wasnik et al., 2019). Longer
⁎
Corresponding author. Corresponding author at: 3/F, Building E12, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macao. E-mail addresses: [email protected] (L. Zhang), [email protected] (Y.-T. Xiang). 1 These authors contributed equally to the work. ⁎⁎
https://doi.org/10.1016/j.ajp.2019.101865 Received 4 October 2019; Received in revised form 1 November 2019; Accepted 1 November 2019 1876-2018/ © 2019 Elsevier B.V. All rights reserved.
Asian Journal of Psychiatry 47 (2020) 101865
Y. Wei, et al.
between August 2011 and May 2019. Following other studies (Wang et al., 2015; Wu et al., 2004) and the recommendation of local health authorities, unmedicated patients were defined as those who did not receive any psychotropic medications (i.e., antipsychotics, antidepressants, mood stabilizer, and benzodiazepines) since the onset of their illness.
duration of untreated psychosis is also associated with worse prognosis (Marshall et al., 2005; Penttilä et al., 2014; Perkins et al., 2005). In developing countries, such as in China, the treatment rate of schizophrenia patients remains relatively low (Padmavathi et al., 1998; Phillips et al., 2009; Ran et al., 2001; Srinivasan et al., 2001). For instance, one study (Phillips et al., 2009) found that 27.6% of Chinese patients with schizophrenia or related disorders never sought help from mental health professionals, while 12% had received treatment in nonpsychiatric services, such as provided by general physicians and Chinese medicine practitioners. A longitudinal study in China found that the proportion of treatment-naïve patients with schizophrenia gradually decreased from 30.6% in 1994 to 20.4% in 2008 (Ran et al., 2015a). Several demographic and clinical factors are associated with the use of medication in schizophrenia patients, such as higher education level, greater access to mental health professionals, higher financial status, less economic burden of treatment and better social support system (Wang et al., 2000; World Health Organization, 2005). However, most studies had a small sample size and were conducted in economically developed areas of China, and therefore, their findings may not be applicable to economically underdeveloped areas (Yang, 2019). In China, most patients with schizophrenia and other severe mental illness usually live in the community, partly supported by the recently developed community-based psychiatric service system. Due to limited health resources, however, schizophrenia patients in economically underdeveloped areas usually have little or no access to mental health services (Xiang et al., 2018). Understanding the pattern of unmedicated schizophrenia patients can help develop appropriate policies and treatment strategies for this vulnerable group. To date, there are no large-scale studies that specifically examined the medication treatment rate of schizophrenia patients in economically underdeveloped areas of China. Therefore, we investigated the pattern of unmedicated schizophrenia patients who were living in economically underdeveloped areas of China, and also explored its demographic and clinical correlates. Due to the differences in financial level, social support and health resources, patients living in both rural and urban areas were studied. We hypothesized that the proportion of unmedicated schizophrenia patients in rural areas would be higher than in urban areas.
2.3. Statistical analysis Data analyses were performed with SPSS 24.0 for Windows (SPSS Inc., Chicago, IL, USA). The comparisons between medicated and unmedicated patients regarding demographic and clinical characteristics were conducted in rural and urban groups separately, using chi-square test, two independent samples t test, Mann-Whitney U test and Fisher’s exact test as appropriate. The Kolmogorov–Smirnov test was used to examine the normal distribution of the continuous variables. Multiple logistic regression analysis with the “enter” method (i.e., all independent variables are entered simultaneously) was conducted to examine the demographic and clinical variables independently associated with unmedicated status in rural and urban groups separately. Considering the large sample size, all demographic and clinical variables were entered as independent variables, while unmedicated status was entered as the dependent variable. The significance level was set as 0.05 (two-tailed). 3. Results A total of 4240 community-dwelling patients with schizophrenia were included, with 1720 (40.6%) rural and 2520 (59.4%) urban residents. The proportion of unmedicated schizophrenia patients was 22.5% (n = 953) in the whole sample, with 32.3% (556/1720) in rural and 15.8% (397/2520) in urban patients (X2=161.1, P < 0.001). Table 1 shows the comparisons of socio-demographic and clinical characteristics between medicated and unmedicated patients by rural and urban areas. In rural areas, unmedicated patients were more likely to be older, male gender, unmarried, and had lower education level, less frequent admissions and longer duration of illness. In urban areas, unmedicated patients were more likely to be older, employed, and had lower education level, better financial status and less frequent admissions. As shown in Table 2, multiple logistic regression analyses revealed that older age (OR = 1.02, 95%CI: 1.01–1.03), male gender (OR = 1.35, 95%CI: 1.07–1.71), unmarried marital status (OR = 0.71, 95%CI: 0.55-0.91), lower education level (OR = 0.39, 95%CI: 0.240.65), longer illness duration (OR = 1.01, 95%CI: 1.00–1.02) and less frequent admissions (OR = 0.46, 95%CI: 0.38-0.54) were significantly and positively associated with unmedicated status in rural areas. In contrast, unmedicated status was significantly associated with older age (OR = 1.01, 95%CI: 1.00–1.02), unmarried marital status (OR = 0.77, 95%CI: 0.61-0.98), employed status (OR = 2.38, 95%CI: 1.87–3.04), lower education level (OR = 0.49, 95%CI: 0.37-0.65), better financial status (OR = 0.60, 95%CI: 0.48-0.76) and less frequent admissions (OR = 0.81, 95%CI: 0.75-0.87) in patients in rural areas. These variables accounted for 18.1% and 11.7% of the variance of unmedicated status in rural and urban areas, respectively.
2. Method 2.1. Patients and study site This cross-sectional study examined the demographic and clinical features of schizophrenia patients registered in the community mentalhealth service system (CMHSS) in Lanzhou, Gansu province. Lanzhou is the capital city of Gansu Province which is the most economically underdeveloped province in China and has around 3.6 million permanent residents (Municipal people’s government in Lanzhou, 2018). Those who were diagnosed with schizophrenia according to the ICD-10 criteria (World Health Organization, 1992) in public psychiatric hospitals were registered in the CMHSS, and were included in the study. There were no exclusion criteria. The Clinical Research Ethics Committee of the Gansu Centers for Disease Control, Gansu province, China approved the study, and in line with the local ethical standards and regulations, written informed consent was not required if data were collected only by a review of the CMHSS.
4. Discussion To the best of our knowledge, this was the first study in China to exclusively examine the medication treatment rate of schizophrenia patients in both economically underdeveloped rural and urban areas. We found that 22.5% of community-dwelling patients with schizophrenia in Lanzhou did not receive psychotropic medications. Gansu province is the most economically underdeveloped area in China (Yang, 2019), therefore, there is a shortage of mental health services compared to other areas (Zhao et al., 2017; Zhu and Wan, 2012), which is
2.2. Assessments Patients’ socio-demographic and clinical data, including age, gender, marital status, residence (rural or urban areas), educational level, employment status, family history of psychiatric disorders, financial status, duration of illness, number of hospitalizations, and treatment status, were retrieved from the CMHSS covering the period 2
Asian Journal of Psychiatry 47 (2020) 101865
Y. Wei, et al.
Table 1 Sociodemographic and clinical characteristics of medicated and unmedicated schizophrenia patients in economically underdeveloped rural and urban areas of China. Variable
Rural areas
Male gender Married Higher education# Employed Family history of psychiatric disorders Poor financial status*
Age (years) Illness duration (years) Number of hospitalizations
Urban areas
Medication-free (n = 556)
Medication-treated (n = 1164)
Statistics
N 304 296 22 501 30
% 54.7 53.2 4.0 90.1 5.4
N 568 686 132 1032 46
% 48.8 58.9 11.3 88.7 4.0
X2 5.2 4.9 25.1 0.8 1.8
df 1 1 1 1 1
431
77.5
855
73.5
3.2
1
Mean 52.4 20.4 0.2
SD 13.4 13.9 0.6
Mean 47.6 15.9 0.9
SD 13.1 11.0 1.5
Z −6.9 −6.0 −12.1
Medication-free (n = 397)
Medication-treated (n = 2123)
Statistics
P 0.023 0.026 < 0.001 0.367 0.173
N 226 175 68 150 27
% 56.9 44.1 17.1 37.8 6.8
N 1167 898 673 412 101
% 55.0 42.3 31.7 19.4 4.8
X2 0.5 0.4 34.2 65.1 2.8
df 1 1 1 1 1
P 0.472 0.510 < 0.001 < 0.001 0.089
0.070
229
57.7
1,494
70.4
24.9
1
< 0.001
P < 0.001 < 0.001 < 0.001
Mean 53.0 20.6 0.9
SD 13.5 13.0 1.5
Mean 49.6 19.3 1.7
SD 12.3 11.5 2.5
Z −5.0 −1.3 −8.2
P < 0.001 0.171 < 0.001
Bolded values: < 0.05; #senior middle school or above; *per capita annual income less than the current local poverty line; abbreviations: SD: standard deviation.
hospitalizations was negatively associated with the likelihood of unmedicated status in this study. More frequent hospitalizations could help patients and their families understand the importance of medication treatment, which could, therefore, reduce the likelihood of ceasing treatment. The relationship between gender and medication treatment has been controversial. Some studies found that untreated schizophrenia patients were more likely to be women (Hou et al., 2018; Wu et al., 2004), while others did not find any gender difference (Padmavathi et al., 1998; Ran et al., 2015a). This study found that unmedicated patients in rural areas were more likely to be men. A multicenter study in China found that male patients had more negative attitude toward antipsychotic treatments (Zhou et al., 2016); in addition, a lower marital rate was found in male schizophrenia patients (Thara and Srinivasan, 1997), especially in rural area of China (Ran et al., 2017; Yang et al., 2012), both of which could reduce the likelihood of helpseeking and being medicated. Longer illness duration was positively associated with unmedicated status in rural patients. With prolonged illness duration, patients were more likely to have negative attitudes towards medication treatment (Zhou et al., 2016), be unmarried (Ran et al., 2017), and have poorer insight and more severe cognitive impairment (Altamura et al., 2015; Carroll et al., 1999), all of which could reduce the acceptance of medication treatment (Bitter et al., 2015; Choudhury et al., 2009; Lambert et al., 2010). This study found that unmedicated patients in urban areas were more likely to be employed and have a better financial status. The possible explanation is that compared to their rural counterparts, urban schizophrenia patients were more likely to work (Yang et al., 2013) and conceal their illness (Loganathan and Murthy, 2008). Consequently, urban patients may often refuse medication treatment in order to reduce the risk of medication-induced side effects. The strengths of this study included the large sample size and inclusion of both rural and urban areas. However, several limitations need to be addressed. First, due to cross-sectional design, the causal relationship between unmedicated status and other variables could not be examined. Second, due to logistic reasons, only Gansu province was included, which limits the generalization of the findings to other economically underdeveloped areas of China. Third, some variables related to treatment status, such as prescription and doses of psychotropic medications, the severity of psychotic symptoms and social support, were not available in the CMHSS. Fourth, no standardized instruments were utilized to measure psychotic symptoms. In conclusion, the rate of unmedicated schizophrenia patients living in the community in Lanzhou is high, particularly in rural areas. Considering the negative health outcomes of unmedicated status, in order to improve the treatment rate in in economically underdeveloped
Table 2 Basic-demographic and clinical characteristics of unmedicated patients in rural and urban areas of China. Rural areas
Urban areas
Variables
OR
95%CI
P
OR
95%CI
P
Age Male gender Married Higher education# Employed Family history of psychiatric disorders Poor financial status* Illness duration (years) Number of hospitalizations
1.02 1.35 0.71 0.39 0.97 1.36
1.01-1.03 1.07-1.71 0.55-0.91 0.24-0.65 0.68-1.40 0.81-2.27
< 0.001 0.011 0.007 < 0.001 0.902 0.232
1.01 1.19 0.77 0.49 2.38 1.33
1.00-1.02 0.94-1.50 0.61-0.98 0.37-0.65 1.87-3.04 0.84-2.11
< 0.001 0.133 0.040 < 0.001 < 0.001 0.214
1.10 1.01
0.85-1.42 1.00-1.02
0.461 0.007
0.60 1.00
0.48-0.76 0.99-1.01
< 0.001 0.480
0.46
0.38-0.54
< 0.001
0.81
0.75-0.87
< 0.001
Bolded values: P < 0.05; #Senior middle school or above; *per capita annual income less than the currently local poverty line; Abbreviations: CI: confidential interval; OR: odds ratio.
probably the major reason for the high rate of unmedicated schizophrenia patients. Schizophrenia patients in rural areas had a higher rate of unmedicated status, which is consistent with previous findings (Hou et al., 2018; Wang et al., 2015; Wu et al., 2004). The mental health resources in rural areas are inadequate compared to in urban areas (Xiang et al., 2018), with rural patients having less access to health education (Phillips, 2001) and lower awareness of the importance of medication treatment of psychiatric disorders (Liu, 2016). Furthermore, rural patients often face discrimination (Loganathan and Murthy, 2008), and as a result, are less likely to seek help from psychiatric professionals (Ran et al., 2015b; Wang et al., 2000). All these factors may contribute to the low medication treatment rate in rural patients. Several socio-demographic factors were significantly associated with unmedicated status in both rural and urban patients. Similar to earlier findings, unmedicated patients were more likely to be older (Padmavathi et al., 1998; Ran et al., 2015a, 2007), less educated (Padmavathi et al., 1998), and unmarried (Ran et al., 2015a; Thara and Srinivasan, 1997). Patients who were older and less educated were more likely to refuse treatment (Hoge et al., 1990; Wang et al., 2000) due to insufficient understanding of the importance of maintenance treatment (Liu, 2016). Married status was usually associated with better social support (Ran et al., 2017), which could improve the rate of medication treatment in schizophrenia. The number of psychiatric 3
Asian Journal of Psychiatry 47 (2020) 101865
Y. Wei, et al.
areas of China, accessible primary mental health services need to be established and mental health education on the importance of pharmacotherapy for schizophrenia should be conducted (Halbreich et al., 2019; Huang, 2011; Lin and Woo, 2018). In addition, effective policies should be implemented urgently (Hill et al., 2019).
China: comparisons within and between rural and urban areas. J. Clin. Psychiatry 79. Huang, Y.-q., 2011. Status quo and challenge of mental health in China. [in Chinese]. Chin. J.Health Policy 5–9. Kurihara, T., Kato, M., Reverger, R., Tirta, I.G.R., Kashima, H., 2005. Never-treated patients with schizophrenia in the developing country of Bali. Schizophr. Res. 79, 307–313. Lambert, M., Conus, P., Cotton, S., Robinson, J., McGorry, P.D., Schimmelmann, B.G., 2010. Prevalence, predictors, and consequences of long-term refusal of antipsychotic treatment in first-episode psychosis. J. Clin. Psychopharmacol. 30, 565–572. Li, A., Huang, X., Zhu, T., 2018. A systematic analysis of online broadcasts of suicidality in China. Asia-pacific Psychiatry 10, e12302. Lin, T.Y., Woo, B.K.P., 2018. Social media as an educational platform against stigma. Asia-pacific Psychiatry 10, e12320. Liu, H., 2016. Analysis on Implementing Situation and Degree of Satisfaction About Basic Public Health Services of Gansu Province in 2014 (in Chinese). Lanzhou University. Loganathan, S., Murthy, S.R., 2008. Experiences of stigma and discrimination endured by people suffering from schizophrenia. Indian J. Psychiatry 50, 39–46. Marshall, M., Lewis, S., Lockwood, A., Drake, R., Jones, P., Croudace, T., 2005. Association between duration of untreated psychosis and outcome in cohorts of firstepisode patients: a systematic review. Arch. Gen. Psychiatry 62, 975–983. Municipal people’s government in Lanzhou, 2018. The Population Division [in Chinese]. http://www.lanzhou.gov.cn/col/col7/index.html?authkey=gj2f1. Padmavathi, R., Rajkumar, S., Srinivasan, T.N., 1998. Schizophrenic patients who were never treated–a study in an Indian urban community. Psychol. Med. 28, 1113–1117. Penttilä, M., Jääskeläinen, E., Hirvonen, N., Isohanni, M., Miettunen, J., 2014. Duration of untreated psychosis as predictor of long-term outcome in schizophrenia: systematic review and meta-analysis. Br. J. Psychiatry 205, 88–94. Perkins, D.O., Gu, H., Boteva, K., Lieberman, J.A., 2005. Relationship between duration of untreated psychosis and outcome in first-episode schizophrenia: a critical review and meta-analysis. Am. J. Psychiatry 162, 1785–1804. Phillips, M.R., 2001. Schizophrenia in China. Dialogues Clin. Neurosci. 3, 112–119. Phillips, M.R., Zhang, J., Shi, Q., Song, Z., Ding, Z., Pang, S., Li, X., Zhang, Y., Wang, Z., 2009. Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey. Lancet 373, 2041–2053. Ran, M.-S., Weng, X., Chan, C.L.-W., Chen, E.Y.-H., Tang, C.-P., Lin, F.-R., Mao, W.-J., Hu, S.-H., Huang, Y.-Q., Xiang, M.-Z., 2015a. Different outcomes of never-treated and treated patients with schizophrenia: 14-year follow-up study in rural China. Br. J. Psychiatry 207, 495–500. Ran, M., Xiang, M., Huang, M., Shan, Y., 2001. Natural course of schizophrenia: 2-year follow-up study in a rural Chinese community. Br. J. Psychiatry 178, 154–158. Ran, M.S., Chan, C.L., Ng, S.M., Guo, L.T., Xiang, M.Z., 2015b. The effectiveness of psychoeducational family intervention for patients with schizophrenia in a 14-year follow-up study in a Chinese rural area. Psychol. Med. 45, 2197–2204. Ran, M.S., Chen, E.Y., Conwell, Y., Chan, C.L., Yip, P.S., Xiang, M.Z., Caine, E.D., 2007. Mortality in people with schizophrenia in rural China: 10-year cohort study. Br. J. Psychiatry 190, 237–242. Ran, M.S., Wong, Y.I., Yang, S.Y., Ho, P.S., Mao, W.J., Li, J., Chan, C.L., 2017. Marriage and outcomes of people with schizophrenia in rural China: 14-year follow-up study. Schizophr. Res. 182, 49–54. Srinivasan, T.N., Rajkumar, S., Padmavathi, R., 2001. Initiating care for untreated schizophrenia patients and results of one year follow-up. Int. J. Soc. Psychiatry 47, 73–80. Thara, R., Srinivasan, T.N., 1997. Outcome of marriage in schizophrenia. Soc. Psychiatry Psychiatr. Epidemiol. 32, 416–420. Wang, H., Song, Y., Yu, B., Yu, S., 2015. Investigation on treatment status of schizophrenia in Mudanjiang City(in Chinese). Journal of Clinical Medical 2, 4696–4698. Wang, P.S., Gilman, S.E., Guardino, M., Christiana, J.M., Morselli, P.L., Mickelson, K., Kessler, R.C., 2000. Initiation of and adherence to treatment for mental disorders: examination of patient advocate group members in 11 countries. Med. Care 926–936. Wasnik, V., Khess, C.R.J., Munda, S., Bijali, S., 2019. Serum prolactin level and its correlation with psychopathology in drug free/drug naive schizophrenia a case control study. Asian J. Psychiatr. 39, 1–5. World Health Organization, 1992. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization, Geneva. World Health Organization, 2005. Improving access and use of psychotropic medicines. Mental Health Policy and Service Guidance Package. Wu, M., Zhou, L., Li, H., Guo, L., Cha, Y., 2004. Current situation of treatment of rural schizophrenic patients (in Chinese). Chin. J. Clin. Rehab. 8, 3642. Xiang, Y.-T., Ng, C.H., Yu, X., Wang, G., 2018. Rethinking progress and challenges of mental health care in China. World Psychiatry 17, 231–232. Yang, L.H., Phillips, M.R., Li, X., Yu, G., Zhang, J., Shi, Q., Song, Z., Ding, Z., Pang, S., Susser, E., 2013. Employment outcome for people with schizophrenia in rural v. Urban China: population-based study. Br. J. Psychiatry 203, 272–279. Yang, Q., 2019. The formulation and implementation of Gansu Provincial government strategic management under the background of "one Belt and one Road" (in Chinese). Fujian Zhiliang Guanli 225. Yang, X., Attane, I., Li, S., Zhang, Q., 2012. On same-sex sexual behaviors among male bachelors in rural china: evidence from a female shortage context. Am. J. Mens Health 6, 108–119. Zhao, W., Pan, W., Ge, P., Jiang, X., Li, J., Xue, L., Wu, Z., Yao, L., 2017. Analysis of mental health service resources in Gansu Province (in Chinese). Disease Control Prev. Bull. 32, 19–22. Zhou, J., Xiang, Y.T., Li, Q., Zhu, X., Li, W., Ungvari, G.S., Ng, C.H., Ongur, D., Wang, X., 2016. Gender differences in attitudes towards antipsychotic medications in patients with schizophrenia. Psychiatry Res. 245, 276–281. Zhu, C., Wan, G., 2012. Rising inequality in China and the move to a balanced economy. China World Econ. 20, 83–104.
Ethical standards The Clinical Research Ethics Committee of the Gansu Centers for Disease Control, Gansu province, China approved the study, and in line with the local ethical standards and regulations, written informed consent was not required if data were collected only by a review of the community mental-health service system (CMHSS) in Lanzhou, Gansu province. We report this study in strict accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Availability of data and materials The Clinical Research Ethics Committee of the Gansu Centers for Disease Control, Gansu province, China that approved the study prohibits the authors from making the research data set publicly available. Readers and all interested researchers may contact Dr. Lan Zhang (Email address: [email protected]) for details. Dr. Zhang could apply to the Clinical Research Ethics Committee of the Gansu Centers for Disease Control for the release of the data. Financial disclosure None. Declaration of Competing Interest All authors declare no conflicts of interest concerning this article. Acknowledgements The authors are grateful to all patients and clinicians involved in this study. References Altamura, A.C., Serati, M., Buoli, M., 2015. Is duration of illness really influencing outcome in major psychoses? Nord. J. Psychiatry 69, 403–417. Bitter, I., Feher, L., Tenyi, T., Czobor, P., 2015. Treatment adherence and insight in schizophrenia. Psychiatria Hungarica 30, 18–26. Carroll, A., Fattah, S., Clyde, Z., Coffey, I., Owens, D.G.C., Johnstone, E.C., 1999. Correlates of insight and insight change in schizophrenia. Schizophr. Res. 35, 247–253. Choudhury, S., Khess, C.R., Bhattacharyya, R., Sanyal, D., 2009. Insight in schizophrenia and its association with executive functions. Indian J. Psychol. Med. 31, 71–76. Cohen, A., Patel, V., Thara, R., Gureje, O., 2008. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr. Bull. 34, 229–244. De Hert, M., Correll, C.U., Bobes, J., Cetkovich-Bakmas, M., Cohen, D., Asai, I., Detraux, J., Gautam, S., Möller, H.-J., Ndetei, D.M., Newcomer, J.W., Uwakwe, R., Leucht, S., 2011. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry 10, 52–77. Halbreich, U., Schulze, T., Botbol, M., Javed, A., Kallivayalil, R.A., Ghuloum, S., Baron, D., Moreira Almeida, A., Musalek, M., Fung, W.L.A., Sharma, A., Tasman, A., Christodoulou, N., Kasper, S., Ivbijaro, G., 2019. Partnerships for interdisciplinary collaborative global well-being. Asia-Pacif. Psychiatry 11, e12366. Higuchi, T., Ishigooka, J., Iyo, M., Yeh, C.B., Ebenezer, E.G., Liang, K.Y., Lee, J.S., Lee, S.Y., Lin, S.K., Yoon, B.H., Nakamura, M., Hagi, K., Sato, T., 2019. Lurasidone in the treatment of schizophrenia: results of a double-blind, placebo-controlled trial in Asian patients. Asia-Pacif. Psychiatry 11, e12352. Hill, H., Killaspy, H., Ramachandran, P., Ng, R.M.K., Bulman, N., Harvey, C., 2019. A structured review of psychiatric rehabilitation for individuals living with severe mental illness within three regions of the Asia-Pacific: implications for practice and policy. Asia-Pacif. Psychiatry 11, e12349. Hoge, S.K., Appelbaum, P.S., Lawlor, T., Beck, J.C., Litman, R., Greer, A., Gutheil, T.G., Kaplan, E., 1990. A prospective, multicenter study of patients’ refusal of antipsychotic medication. JAMA Psychiatry 47, 949–956. Hou, C.L., Chen, M.Y., Cai, M.Y., Chen, Z.L., Cai, S.B., Xiao, Y.N., Jia, F.J., 2018. Antipsychotic-free status in community-dwelling patients with schizophrenia in
4