6.2.1. BASELINE DEMOGRAPHIC CHARACTERISTICS
There were slightly more males than females meeting the inclusion criteria and hence recruited into this study. The male to female ratio was 1.2 to 1. Earlier studies of the epidemiology of schizophrenia as well as the information documented in Diagnostic and Statistical Manuals (DSM) (American Psychiatric Association, 1994) suggest equal rates of the disorder among male and female subjects. However, more recent findings with improved methodology as well as systematic reviews of the older studies have shown that men are more likely to receive a diagnosis of the disorder than women (McGrath et al, 2004., McGrath, 2007., Aleman et al, 2003). These reviews suggest that for every 3 male diagnosed with the disease, there are 2 females. However, rates of schizophrenia diagnosis in females may increase to catch up with the rate in male subjects as the mean age of the relevant sample increases. In this study, only subjects aged between 16 and 45 years were recruited. The mean age of the sample was 28.7 (SD 6.4) years and female subjects were older at onset and at presentation with the disease. Schizophrenia is known to have a later onset in females compared to males (Mcgrath et al, 2004). Female patients with the disease are also known to present or seek treatment later than males especially in low and middle income countries, as a lower priority is often given to paying for treatment for females with health problems compared to males (Large and Nielsen, 2008). There may also be some apprehension that a diagnosis of a psychotic disorder may affect a woman’s prospect of getting married. All the participants in this study had at
age of onset of 29 years, a majority of subjects in the sample (73.8%) had completed secondary or higher education. However, schizophrenia often leads to a deterioration of personal functioning. This is reflected in the finding in the present study that 92.9% of the subjects were unemployed, while 73.8% were un-married at recruitment into the study despite their pre-morbid educational attainment.
6.2.2. BASELINE CLINICAL CHARACTERISTICS 184.108.40.206. DURATION OF UNTREATED PSYCHOSIS
The mean duration of untreated psychosis was 38.9 months and a median of 26 months, with 61.9% of the subjects having illness duration longer than 12 months. Such a long duration of untreated psychoses is a common feature in low and middle income countries (Gureje, 1991., Murphy et al, 1998., Tang et al, 2007). In fact, some studies have suggested a causal relationship between low income and treatment delays in low and middle income countries (Large et al, 2008). In the absence of insurance, the cost of health-care may prevent many patients from seeking treatment. Qualitative mental health care may also be absent altogether in many areas (Mcready and Ohaeri, 1994). However, it is pertinent to note that this study relied on subjects presenting at the psychiatric unit for the first time with schizophrenia, having never received any orthodox treatment. A large proportion of psychotic patients in low income countries may present initially to traditional or faith healers because of socio-cultural beliefs about psychosis (Naqvi et al, 2009).
In the present study, onset of psychosis was defined as the presence, for one week or more, of one of the following psychotic symptoms; delusions, hallucinations, marked thought disorder, marked psychomotor disorder, and bizarre grossly inappropriate and/or disorganised behaviour, with a marked deterioration of functioning. The investigator relied on information provided by the patients and a close relation. Therefore, it was difficult to estimate the influence of factors such as recall bias or cultural differences in the conceptualisation of illness, on the exactness of the reported date at onset. Inclusion into the study was also limited to those who were between 16years and 45 years. The upper limit of 45years was used to ensure the generalisability of the results, while also avoiding the inclusion of late onset cases. Late onset of illness is a common characteristic of female subjects, and those with paranoid schizophrenia.
This strategy is by no means full proof, and the possibility of bias in recruitment of subjects with certain illness profile remains. Therefore, while the average age at onset of illness of 24.6 years reported in this study may fall within the usual expected range, factors inherent in the methodology of this study may also have influenced this value. Epidemiologic studies from developing countries report a wide variation in the age at onset of schizophrenia (Eranti et al, 2012). This observation has previously led to speculations that differences exist between developed and developing countries in the age at onset of schizophrenia (Gangadhar et al. 2002). The variation in the age at onset of schizophrenia across studies may be related to differences in definition, settings, age limit for inclusion, and diagnostic criteria employed in the different studies.
In this study, the Positive and Negative Syndrome Scale (PANSS) five factor solution was used to generate a parsimonious reduction of the multi-dimensional psychopathology of schizophrenia. This is in view of the stability and widespread acceptance of the five factor model, at least in more recent studies of the outcome of schizophrenia (Llorca et al, 2011). The schizophrenia psychopathology in this sample was well distributed along the lines of the five empirical factors, with a mean total PANSS score of 73.3 and a mean Clinical Global Impression of severity (CGI-S) score of 5.1, suggesting a sample populated by markedly ill schizophrenia patients at baseline. It would be expected that such a degree of illness severity would be associated with serious social, occupational and school functioning as well as poor insight. The mean Social and Occupational Functioning Assessment Scale (SOFAS) at baseline was 44.6, and about 94% of the subjects had poor insight. There was no attempt to selectively include patients with a certain distribution of psychopathology, or indeed a certain degree of severity of illness in this study so as to recruit a sample that is as close to the real life situation as possible.
220.127.116.11. PREMORBID ADJUSTMENT
The mean scores for pre-morbid academic and social functioning in this study were higher than those reported in the original work on the Pre-morbid Adjustment Scale (PAS) by Cannon-Spoor et al. (Cannon-Spoor et al, 1982). Patterns similar to those reported in the original report on the scale as well as in subsequent studies of
schizophrenia patients were however found in this study. The most prominent finding in this cohort was that of a poorer pre-morbid academic functioning from childhood through adolescence, whereas, the childhood social functioning was comparatively better. However, social functioning deteriorated through early to late adolescence. This may suggest that a rapid deterioration in pre-morbid social functioning in the individual may herald the onset of schizophrenia. Some have argued that pre-morbid deterioration either represents the onset of schizophrenia, or is an ‘ultra at risk-factor’ for the disorder (Buchanan et al, 1990., Peralta et al, 2012). Later onset deterioration of social functioning has always been seen as a clear sign of pre-morbid mal-adjustment, especially when they involve activities in interpersonal relationship occurring in settings outside the home (Strauss et al, 2012). Such activities occur in the pathway to the establishment of close emotional and sexual contacts in these circumstances. A certain level of social-sexual functioning is expected in the adolescent before the attainment of adult level functioning. Indeed some investigators have suggested that such rapid deterioration in social functioning in early adolescence may be a harbinger of certain types of poor prognostic psychotic disorders such as deficit schizophrenia (Buchanan et al, 1990., Strauss et al, 2012., Peralta et al, 2012). These studies also reported patterns of deterioration in academic functioning in relation to social functioning as is seen in the present study. This pattern is such that whereas social deterioration was observed during the early adolescent years, poor pre-morbid academic functioning was observed from childhood, and remained poor through the adolescent years. It is pertinent to note that childhood pre- morbid functioning measured using the PAS are those occurring from the age of 6years and 11 years. As such it may be difficult to determine if the onset of the deterioration
dysfunction is observed in the prodrome to schizophrenia.