The study was carried out in 1994, some 12 years after the Chinese National Epidemiological Study of Mental Disorder of 1982. It was carried out in only one of the 12 areas of the 1982 survey, and was limited to subjects in a rural area with schizophrenic syndromes. The same methods were used for both the studies, and the prevalence rates found in 1994 were very similar to those found in rural areas in 1982. This suggests that comparisons can be made between the two sets of results with a reasonable degree of confidence, and the nature of both the studies makes it unlikely that many subjects were missed.
The authors of this paper have not explained some of the details of their procedures, and offer no comments on a number of interesting issues, nevertheless, these omissions do not detract from the importance of the two main findings. These are, first, that treatment of people suffering from schizophrenic syndromes with regular antipsychotic medication is better than similar, but irregular, treatment and is also better than ‘traditional’ treatments. It is certainly very much better than no treatment at all. The second finding is that it is important to differentiate between different types of outcome, since although 82% of the patients in the never-treated group were assessed at the 2-year follow-up as having ‘marked’ symptoms or worse, 78% of them were doing part-time or full-time work (in a rural population). Unfortunately, the minimal criteria for part-time work are not given, but it seems likely that the presence of a variety of clinical symptoms was no bar to some sort of useful occupation in many of the patients.
These points are not sensational or novel, but the scarcity of reports on untreated patients of this type, the methods employed, and the comparatively large numbers involved, all combine to justify publication of this report, in spite of its other shortcomings.
One disappointment is that the proportion of patients receiving no treatment at all has increased (30.6% in this study), rather than decreased (20.3% in 1982). The reasons for not receiving treatment should be a useful stimulus for those in China responsible for the provision of services; they are: lack of money, 35.3%; relative's uncertainty about the patient's illness or not thinking that the patient is suffering from mental illness, 29.5%; patients refusing to accept drug treatment, 18.6%; having no relatives caring for patients, 14.7%; local unavailability of medical facilities, 1.9%. These proportions show that a large part of the problem lies in unfavourable attitudes to mental illness, rather than lack of availability of services. “ Lack of money” also reflects the absence of free treatment at the point of delivery. There is an expectation in China that family or employers will provide payment, since the idea of a comprehensive health service free at the point of delivery, paid for by national or local taxation, has not been developed.
The history of the patients in the never-treated group is not described as clearly as it might have been. Of the total of 510 patients who constitute the total prevalence group, 156 were in the never-treated category. Unfortunately, the authors do not say how many of these were among the 367 found to have schizophrenia at the time of the survey (the point prevalence group), or how many were included in the 143 who did not receive that diagnosis at the time of the survey, but who had been diagnosed at some point previously.
The 2-year follow-up information would probably allow a more detailed presentation than the authors give here. The four tables all refer to the 156 patients in the never-treated group, so the data on clinical state and duration of illness in these tables presumably refer to what was found at the time of the survey. There are two clear statements that all 510 patients with schizophrenia found were followed up for 2 years from the date of the survey, but the 2-year follow-up data are given only for the 156 members of the never-treated group, in the form of a narrative paragraph headed ‘outcome at follow-up’, rather than as another table. Of the 156, 55 accepted treatment during the 2-year period, 95 remained without treatment, and six died. Again, it is not stated how many of those accepting or not accepting treatment came from the 367 people in the point prevalence group, and how many from the 143 previous-diagnosis-only group. It would be interesting to know what effect the eventual acceptance of treatment had upon the subjects with long-standing illness.
The authors correctly emphasise that these findings demonstrate the benefits of antipsychotic medication, and do not support the idea that in rural populations schizophrenic illnesses often have a comparatively good outcome.
It could be argued that what is described as regular treatment is not necessarily a complete course of treatment for people with clearly schizophrenic illnesses, since the minimum for regular treatment was 1 year of regular antipsychotic medication. However, this represents a very significant intervention, whatever the details. The major point is that in terms of duration of illness, this was clearly superior to no treatment, irregular and traditional treatment.
In contrast, Table 3 shows that in terms of complete remission, any form of treatment is better than none, with little difference between regular, irregular and traditional treatments. But clear differences emerge between types of treatment in the lesser degrees of remission.
A more detailed examination of the relationships between the clinical outcome categories, the rather brief statements about ability to work, and the social disability ratings would be well worthwhile. It is clear that assessments on these three aspects of the subjects do not coincide, but, for instance, how they do or do not agree with each other for men and for women would be of great interest.
One of the purposes of large surveys is to highlight points of interest that can be clarified in subsequent smaller studies, and it is to be hoped that the authors will be able to do this in the future.
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