Psychiatryand
PsychiatricEpidemiology
Soc PsychiatryPsychiatrEpidemiol (1993)28:267 274
Social
9 Springer-Verlag 1993
Characteristics of hospital-treated schizophrenia
in
Paulo, Brazil
P. R. Menezes and A. H. Mann
Section of Epidemiologyand General Practice, Institute of Psychiatry,London,UK
Accepted:23 June 1993
Summary. This paper reports a study on the prevalence of
hospital-treated schizophrenia in a large urban centre in
Brazil. A sample of 124 individuals from a defined catchment area of Silo Paulo consecutively admitted to psychiatric hospitals due to acute episodes of non-affective psychoses were assessed by standardized instruments for
mental state and social adjustment. The sample was predominantly white (72.6%), single (65.2%), Catholic
(61.3 % ) and not born in that city (58.9 % ). Eighty-six subjects fulfilled DSM-III-R criteria for schizophrenia
(69.3 % ), 15 were classified as schizophreniform psychosis
(12.1%), and 7 as schizoaffective (5.6 %). Almost twothirds showed Schneider's 'first rank' symptoms. Social
adjustment before admission was poor or very poor in
nearly half the sample. Mean age at onset was 3.2 years
earlier in men than in women (P = 0.007). No gender differences in mental state or social adjustment were observed. Individuals born outside S~o Paulo State had significantly more florid symptoms than those born in that
state. These findings suggest that the features of schizophrenia in a large urban centre of Brazil are consistent
with the patterns of schizophrenia described in Western
developed countries.
though this survey was mainly focused on minor psychiatric disorders, it yielded global prevalence rates for psychoses, as defined by the DSM-III ranging from 0.2% to
2.0 % according to centre.
Clinical features of schizophrenia have also been investigated. Sougey et al. (1987) recorded the symptoms of 70
schizophrenics admitted to two psychiatric hospitals in the
city of Recife, finding Schneider's 'first-rank' symptoms
(FRS) in 46 (65.7 %) patients. Shirakawa (1989) assessed
the social adjustment of 44 schizophrenic patients who attended a private practice office in Sgo Paulo for many
years. More than 40 % had poor social functioning, and
only 6 patients (13.6 % ) received salaries sufficient to support their independence. However, in Brazil there has not
yet been any proper description of this disabling condition
based upon a systematic sample and standardized assessments. Recent changes in the Brazilian public health system, which lead to regional delivery of care to a larger proportion of the population, has created more favourable
conditions for the execution of epidemiological investigations on mental health problems (Santana et al. 1988).
Urban development in Brazil
Schizophrenia is becoming an important public health
problem for developing countries, with a projected increase of 87 % in the number of treated cases between
1975 and the year 2000, based on the effect of population
changes (Kramer 1980). In Brazil, it is estimated that from
1985 to the year 2000 there will be an increase of 600,000
cases of schizophrenia, a 50 % growth in the number of
cases (Levav et al. 1989).
Despite these projections, epidemiological data about
the characteristics of schizophrenia occurrence in Brazil
are scarce. Studies based on routine clinical diagnoses
found that schizophrenia accounted for almost one-third
of all psychiatric admissions (Araujo 1955; Souza 1983).
Almeida et al. (1992) carried out a community-based survey on the prevalence of psychiatric morbidity in three
urban centres of Brazil, one of which was S~o Paulo. A1-
Economic growth since 1960 has radically changed the
population structure and its distribution in Brazil. In 1965,
55 % of Brazilians lived outside cities, but with rapid industrialization there has been a massive move from
country areas to the cities, so that by 1987 only 28 % of the
population were living in rural areas (Harvey 1987). The
country has developed marked social inequalities, with
only 3 % of the population earning US$1500 or more per
month and 44.5 % having a monthly income of US$150 or
less, according to the 1991 census (VEJA 1993). Illiteracy
rates vary according to region, with a national average
of 18 %. Although the gross national product per capita is
2.7 times higher and the number of televisions per
1000 people is three times higher than the average for
countries of equivalent development, some health indicators are worse: infant and maternal mortality rates, for
268
example, which are 50 % and 35 % higher than average,
respectively (Haines 1993).
Situated in South East Brazil, Silo Paulo is its largest
city and main economic centre, with a population of 11.5
million people (IBGE 1992). During the last decade its
average annual population growth rate was 1.15 % and
was due equally to natural growth and immigration from
other areas of the country, mainly from the North East.
Some 8 % of the population live in shantytowns, and another 28 % in slums. The average mortality rate in children under 5 is 35 per 1000, but varies from 8.1 to 76 per
1000, according to the district of the city (Forattini 1991).
Similar wide variations are found regarding education and
availability of piped water and sanitation. The costs of living for the poor are the highest in the country.
Health care in Brazil
The health care system funded by the government has expanded and changed considerably in the last 30 years
(Roemer 1986). Until 1987, the administration of medical
care deliveries was the responsibility of the social security
ministry, whereas preventative activities were the responsibility of the health ministry (Haines 1993). From 1988
the administration of health care has been decentralised
to state and municipal control, with regionalised planning
for delivery of care. Most of the medical care is provided
by private hospitals, which are paid on the basis of fee-forservice by the government. The availability of such care is
extremely varied across the country, with the highest concentrations in the South Eastern region. Contrasting with
other regions of the country, in the city of Sio Paulo there
is a network of public primary health centres covering
most of the urban area, and some public hospitals and
emergency units have been built in the most deprived
areas, as the result of a municipal policy, but their number
is still below the actual needs of its population (Iacoponi
1989). In addition to publicly funded services, wealthier
people tend to buy into private medical care, whereas the
poor purchase non-prescription drugs direct from pharmacies.
Although there are no accurate statistics, the role of
traditional healing as an alternative to formal medicine
has declined, especially in urban centres (Roemer 1986).
This trend is exemplified on childbirth statistics: in 1960
the majority of deliveries were supervised by untrained
traditional attendants in the mother's home, whereas by
1981 almost 80 % occurred in hospitals. However, alternative sources of help are still sought at the same time as formal medical consultation by many people, commonly
when the problem is in the area of mental illness (Iacoponi
1989).
Psychiatric services
Psychiatric services were almost exclusively located in
psychiatric hospitals until the early 1980s (Marl 1983).
Since then there have been several government initiatives
aimed at changing the orientation towards a community-
based approach (Alves et al. 1992). As a consequence, the
number of psychiatric beds has fallen by 20 % in the last
8 years, and there has been an increase in the number of
non-residential facilities, such as psychiatric out-patient
clinics, but these are still far from ideal. The distribution of
psychiatric beds is very uneven, ranging from 0.04/1000 of
the population in the Northern region to 0.84/1000 in the
South East (Alves et al. 1992).
The catchment area chosen for this study is a health district located in the Northern region of the city of Sio
Paulo, identified as the 'Sistema Descentralizado e Unificado de Safide Regiio 6' (SUDS-R-6). Local psychiatric
facilities comprise two psychiatric out-patient clinics, an
emergency unit with 24-h on-duty psychiatrists, a 20-bed
psychiatric ward in a general hospital, and three psychiatric hospitals with a total of 1500 beds, for both male and
female adult admissions. The local population is estimated to be 950,000 inhabitants, indicating a provision of
1.58 psychiatric beds per 1000 of the population. All the
psychiatric admissions are centrally recorded in a psychiatric register on a daily basis.
The pathway of care for an individual who presents
with a psychotic crisis varies. One of the commonest ways
of getting into the psychiatric care system is through the
emergency unit, because patients will be seen by a psychiatrist on the day of the consultation. They may receive
treatment there for a short period (up to 36 h), after which
they may be referred to one of the out-patient clinics, be
admitted to psychiatric hospital, or be sent back home
with a prescription. When discharged from hospital patients may be referred to the out-patient clinics, but many
do not seek medical care until the onset of a new crisis. Patients under 18 may have psychiatric care in the out-patient clinics or the ward in the general hospital, or seek attention in specialised centres outside the region. Patients
presenting with behavioural disturbances, such as violent
or anti-social behaviour, may be taken in by the police and
then sent to the emergency unit.
The present investigation is the first module of an ongoing prospective outcome study of schizophrenia in Sio
Paulo. A sample of individuals who presented with schizophrenic symptoms and were consecutively admitted to
psychiatric hospitals in the study catchment area was assessed with standardised measures. This paper presents
socio-demographic and socio-economic characteristics,
the clinical profile and level of social disability of the
patients in this sample, who are to be followed up for
2 years.
Method
Selection of subjects
All patients aged between 15 and 44 and resident in the
area of the SUDS-R-6 who were admitted to the three
psychiatric hospitals in the area or to the psychiatric ward
in the general hospital during the period between 1 June
to 22 August 1991, and for whom the admission diagnosis
was schizophrenia, paranoid psychosis or any other functional psychosis- according to the 9th version of the Inter-
269
national Classification of Diseases ( W H O 1975) - were
identified, through weekly visits to the psychiatric register
by the main investigator (R R. M.). Medical records were
then checked, and exclusion and inclusion criteria were
applied. Exclusion criteria were: alcohol or drug dependence in the last year, severe mental retardation, organic
psychoses (including drug-induced psychoses), epilepsy,
hearing or speech difficulties that could impede the administration of interviews, and intention of leaving S~o
Paulo after discharge from the psychiatric hospital (this
criterion was set because of the follow-up study). Inclusion criteria were at least one of the following symptoms:
mood-incongruent delusions, definitely inappropriate or
unusual behaviour (such as talking or laughing on his/her
own when there is no-one else about, collecting rubbish),
hallucinations, disorders of thinking or language (other
than acceleration or retardation); or at least two of the following: psychomotor disturbance (such as excitement,
posturing, waxy flexibility, stupor), social withdrawal,
overwhelming fear, and self-neglect. Patients eligible for
entry into the study were interviewed by the main investigator (R R. M.) within 2 weeks of admission to assess their
mental state. An interview with a 'key informant', generally a relative of the patient, was held subsequently but
still within 2 weeks of admission. The interview included
the scale to assess social adjustment, and was carried out
by the investigator (RR.M.) or his research assistant
(M.S.).
Assessm en t
Assessments were carried out in a standardized way for all
patients, and information was collected from three main
sources: the medical records, the patients, and their key
informants. Data gathered included:
1. Socio-demographic data: sex, age, ethnic group, marital status, religion, educational level, occupational status,
number of persons per room in the household, and monthly per capita income (total income in the household
divided by number of people).
2. Psychiatric history: obtained from medical case records and interviews with key informants. Age at onset and
number of previous psychiatric admissions were recorded, as was the clinical diagnosis given by the psychiatrist in the emergency unit at the time of admission, coded
according to ICD-9.
3. Present State Examination: mental state was assessed
using the 9th version of the Present State Examination
(PSE) (Wing et al. 1974). The investigator was trained in
the use of the instrument at the M R C Social Psychiatry
Unit, in London, and used a Portuguese translation of the
instrument (Caetano and Gentil 1983). By addition of a
30-item questionnaire covering longitudinal aspects of the
disorder, DSM-III-R (APA 1987) diagnoses were also obtained.
4. Social adjustment: a portuguese translation (Chaves
et al. 1990) of the W H O Psychiatric Disability Assessment
Schedule ( W H O / D A S ) ( W H O 1988) was administered
by one of the two interviewers, a psychiatrist R R. M.) and
a psychologist (M. S.). Sections 1 (Overall Behaviour), 2
Table 1. Sodo-demographic characteristics of the study sample by
sex (n = 124)
Age group (years)
15-24
25-34
35-44
Ethnic group
White
Black
Oriental
Mixed
Place of birth
SP capital
SP state
South-East
North-East
Other
Religion
Catholic
Evangelic
Other
None
Marital status
Single
Married
Separated
Widowed
Education
Illiterate
Less than 4 years
4-8 years
9 years and more
Occupational status
Working regularly
Some activity
No occupation
Sickness benefit
Retired
Housewife
Persons per room"
1 or fewer
1.1-2.0
More than 2.0
Monthly per capita
income (US$)b
50 or less
51-100
101-150
150-200
201-500
More than 500
Male (%)
n = 69
Female (%)
n = 55
Total (%)
n = 124
13 (18.8)
26 (37.7)
30 (53.5)
7 (12.5)
25 (45.5)
23 (41.8)
20 (16.1)
51 (41.1)
53 (42.7)
57 (82.6)
0 (0.0)
3 (4.3)
9 (13.0)
33 (60.0)
4 (7.3)
2 (3.6)
16 (29.1)
90 (72.6)
4 (3.2)
5 (4.0)
25 (20.2)
27 (39.1)
11 (15.9)
14 (20.3)
16 (23.2)
1 (1.4)
24 (43.6)
8 (14.5)
5 (9.1)
15 (27.3)
3 (5.4)
51 (41.1)
19 (15.3)
19 (15.3)
31 (25.0)
4 (3.2)
47 (68.1)
14 (20.3)
5 (7.2)
4 (5.8)
29 (53.7)
13 (24.1)
9 (16.7)
3 (5.6)
76 (61.3)
27 (21.8)
14 (11.3)
7 (5.6)
52 (75.4)
9 (13.0)
7 (10.1)
1 (1.4)
29 (52.7)
12 (21.8)
12 (21.8)
2 (3.6)
81 (65.3)
21 (16.9)
19 (15.4)
3 (2.4)
4 (5.8)
9 (13.0)
38 (55.0)
18 (26.0)
3 (5.5)
19 (34.6)
18 (32.7)
15 (27.3)
7 (5.6)
28 (22.6)
56 (45.2)
33 (26.6)
18 (26.1)
4 (5.8)
27 (39.1)
9 (13.0)
11(15.9)
n = 69
39 (56.5)
20 (29.0)
10 (14.5)
6 (10.9)
5 (9.1)
24 (42.6)
5 (9.1)
2 (3.6)
13 (23.6)
n = 54
22 (40.7)
19 (35.2)
13 (24.1)
24 (19.3)
9 (7.3)
51 (41.1)
14 (11.3)
13 (10.5)
13 (10.5)
n = 123
61 (49.6)
39 (31.7)
23 (18.7)
n = 66
22 (33.3)
25 (37.9)
6 (9.1)
6 (9.1)
6 (9.1)
1 (1.5)
n = 54
20 (37.0)
19 (35.2)
7 (13.0)
5 (9.3)
2 (3.8)
1 (1.9)
n = 120
42 (35.0)
44 (36.7)
13 (10.8)
11 (9.2)
8 (6.7)
2 (1.7)
a Information missing in one subject
b Information missing in four subjects
(Social Role Performance) and 5 (Global Evaluation) of
the schedule were used. Adjusted scores for sections i and
2 were obtained by summing up all valid scores (different
from 9) and dividing by the number of valid items ( W H O
1988). The higher the adjusted score in a section, the
worse the functioning in the areas covered by that section.
Twenty subjects were each interviewed by the two investigators together for a reliability test.
270
Analysis
Frequency distributions of socio-demographic and
socio-economic variables, psychopathological status,
and social disability levels were examined. Chi-square
tests were calculated for categorical variables, and t-tests
for comparisons of continuous variables between two
groups, with the statistical package Epi Info 5 (Dean
et al. 1990). Inter-rater reliability for the DAS was assessed by intra-class correlation coefficients (Bartko
1991).
come ranged from US$16.50 to US$ 750; 71.7% of the
individuals had a per capita monthly income of US$100 or
less.
Psychiatric characteristics
The mean age in the sample was 32.6 years (SD -- 6.9), and
it was predominantly white (72.6 %), single (65.2 %),
Catholic (61.3 %) and born outside Sgo Paulo (58.9 %)
(Table1). Thirty-five subjects (28.2%) had had fewer
than 4 years of education. Fifty-one (41.1% ) had no current source of income and relied on their families to survive; 33 patients had some occupation, either as registered
employees or as self-employed; 27 individuals were living
on social benefits due to illness, with a majority of males in
this situation (Z 2 = 4.75, 1 dr, P = 0.03). Sixty-one subjects
(49.6 %) lived in households with up to one person per
room, and 21 (18.7 %) lived in very crowded houses, with
more than two persons per room. Per capita monthly in-
Seventy-three subjects received a diagnosis of schizophrenia on admission to hospital (58.9%), with a predominance of subtype 'unspecified' (n = 22), followed by the
subtypes 'paranoid' (n = 19) and 'residual' (n = 15). For
most of the remaining subjects (39.5 %) a diagnosis of
'other functional psychoses' (n = 49), subtype 'unspecified' (n = 44) was recorded. Paranoid psychosis was rarely
given as a clinical diagnosis (n = 2).
Eighty-six subjects (69.3 % ) fulfilled DSM-III-R criteria for schizophrenia, 15 were classified as having schizophreniform psychosis (12.1%), and 7, schizoaffective
(5.6 %). Thirteen subjects were classified as having affective disorders, with 7 as bipolar and 6 as depressive; 3 subjects fulfilled criteria for 'other psychoses'.
The PSE was applied to all individuals included in the
study. Eighty-one subjects (65.3 % ) were classified by the
C A T E G O program as class 'S + ', with another subject assigned to class S?. Thirty-three subjects (26.6 %) were assigned to other classes of non-affective functional psychoses (P +, P? and O?); the remaining 8 (6.4 %) were assigned to affective-like classes (M +, M?, D + and R + ),
and 1 subject was assigned to class X, which means nonspecific symptoms. The most frequent syndromes were
'Affective Flattening' (77.4 %), 'Nuclear Syndrome'
(62.1%), 'Non-specific Psychoses' (63.7 % ), 'Delusions of
Reference' (58.9 % ), 'Delusions of Persecution' (57.2 % )
and 'Sexual and Fantastic Delusions' (57.2 %). The average age at onset was 24.3 years (Table 2), ranging from 14
to 44 years. The average lenght of illness was 8.3 years.
For 30 subjects (24.4 %) the admission in the study period
was the first admission, and another 34 (27.6 % ) had had
10 or more previous psychiatric admissions.
Table 2. Psychiatric characteristics of study subjects
Social adjustment
Results
Initially, 217 patients were identified at the psychiatric admissions register, but 93 of these were excluded because
they met one or more of the exclusion criteria. Reasons for
exclusion included usual residence outside the catchment
area (n = 20), alcoholism (n = 19) and drug dependence
(n = 10). Ultimately, 124 patients (57.1%), 69 men and
55 women, were included in the study.
Socio-demographic characteristics
Mean age at onset (years)
Mean length of illness (years)
Mean DAH subscore
Mean BSO subscore
S + (%)
Total
Men
(n = 124) (n = 69)
24.3
22.9
8.3
9.5
10.6
9.9
4.9
5.1
65.3
65.2
Women
(n = 55)
26.1
6.7
11.5
4.7
65.5
P
0.011
0.021
0.31
0.53
0.98
DAH, Delusions and hallucinations;BSO, behaviour and speech
The Disability Assessment Schedule (DAS) was applied
to 115 patients (92.7 %). In 3 cases it was not possible to
obtain information from the relatives because of lack of
contact with the patient in the previous month. The remaining 6 cases had been at home less than 15 days between the index admission and a previous one, which was
not sufficient time to complete schedule sections 1, 2 and
Table 3. Distribution of DAS adjusted scores for sections 1 and 2
Overall behaviour"
Social role
Performancea
0.0043.99
45
(39.1)
30
(26.3)
1.00-1.99
21
(18.3)
16
(14.1)
DAS, World Health Organization PsychiatricDisability Assessment Schedule
Percentages in brackets
2.00-2.99
22
(19.1)
26
(22.8)
3.00-3.99
19
(16.5)
22
(19.3)
4.00-4.99
8
(7.0)
20
(17.5)
271
100
.
-~_~ -_~-_- ~ _ ~
.Q
90
80
,o
e~
70
60
50
"5
40
0
30
E
.e e "~ o-e
/
9
o"
males
---o--
females
20
10
0
" ~ "
" "
~"
. . . . . . . . . . .
l
I
I
1
I
t
~
t
1
I
1
I
I
1
I
a g e a t onset
80
e
9
SP
:2
70
e
GO
e
---~--
Other
''
/T
50
8 40
~
O.
30
20
10
0
I
I
I
I
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I
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I
I
I
I
I
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;
;
;
;
I
I
I
I
Fig. 1. Cumulative percentage of age at
onset by sex (n = 124)
Fig.2. PSE syndrome profiles according to
place of birth (n = 124). NS, Nuclear
syndrome; CS, catatonic syndrome; IS,
incoherent speech; RS, residual syndrome;
DD, depressive delusions and hallucinations; SD, simple depression; ON,
obessional neurosis; GA, general anxiety;
SA, situational anxiety; HT, hysteria;
AE affect flattening; HM, hypomania;
AH, auditory hallucinations; PE, delusions
of persecution; RE, delusions of reference;
GR, grandiose and religious delusions;
SF, sexual and fantastic delusions; VH,
visual hallucinations; OH, olfactory hallucinations; OV, overactivity; SL, slowness;
NP, non-specific psychosis; DE, depersonalization; ED, special features of depression;AG, agitation; NG, self-neglect;
IR, ideas of reference; TE, tension;
LE, lack of energy; WO, worrying, etc.;
IT, irritability; SU, social unease; IC, loss of
interest and concentration; HZ hypochondriasis; OD, other symptoms of depression;
OR, organic impairment; SC, "subcultural"
delusions of hallucinations; D/, doubtful
interview
syndrome
5. The inter-rater reliability of the DAS was good, with
intra-class correlation coefficients (ICC) for each item
ranging from 0.88 (95% CI = 0.72-0.95) to 1.00 (95%
CI = 0.99-1.00). The ICC for global evaluation was 0.93
(95 % C.I. = 0.83-0.97).
The average adjusted scores for sections 1 (Overall Behaviour) and 2 (Social Role Performance) were 1.67 and
2.25, respectively. Subjects tended to have higher scores in
section 2 than in section 1 (Table 3). In section 5 of the
schedule, global evaluation of social disability, 57 subjects
were rated as 3 or 4 ('poor adjustment' and 'very poor adjustment', respectively), with the remaining 57 subjects
evenly distributed between scores 0, 1 and 2 ('excellent or
very good', 'good' and 'fair' adjustments). For 1 subject it
was not possible to give a global evaluation score.
Gender differences
A significantly greater proportion of white subjects were
male (Z z = 7.86, 1 dr, P = 0.005) (Table 1). The proportion
of single subjects was also greater in male than in female
patients (Z 2 = 6.92, 1 df P = 0.008). The proportion with
4 or more years of education was higher for men than
for women; the difference was statistically significant
(Z 2 = 6.76, 1 dr, P = 0.009).
The main difference between genders concerned age at
onset (Fig. 1). Men became ill at younger ages than
women (Table 2); the relative risk of age at onset less than
26 years for men over women was 1.74 (95 % C.I. = 1.16 to
2.62, P--0.002). Men had more years of illness than
women (Table 2), with averages of 9.5 years and 6.7, respectively. Women were significantly more represented
in the first admission group (19vs 11men, X 2= 5.78,
P = 0.016).
PSE syndrome profiles for men and women were similar. Of the 38 syndromes, only 3 differed between sexes at
a statistically significant level. These were 'depressive delusions and hallucinations' (DD) ( P = 0.012), 'olfactory
hallucinations' (OH) (P=0.012), and 'lack of energy'
(LE) ( P = 0.048). Concerning social adjustment, gender
differences for adjusted scores of sections 1 and 2 were
small and non-significant. There was no significant difference for 'global evaluation' scores either.
Place of birth
Those born in the state of Silo Paulo were compared with
those born in other states of Brazil (Table 4, Fig. 2). There
were no significant differences between these two groups
regarding age, sex, mean age at onset of illness, and mean
272
Table 4. Psychiatric characteristics according to place of birth
length of illness. Those not born in Sgo Paulo State were
significantly more often classified as class S + by the
CATEGO program than those born in that state. Their
average subscore for delusions and hallucinations (DAH)
was also significantly higher, and this difference remained
after controlling for length of illness, years of education
and per capita monthly income. The average subscore for
observed problems with behaviour and speech (BSO) was
also higher, but not at a statistically significant level.
There were no cases excluded due to intention to leave
Silo Paulo, nor did any patients refuse to participate in
the study.
Inclusion criteria were based on a very broad range of
symptoms, and might have allowed the inclusion of a reasonable number of other psychiatric conditions than schizophrenia. However, the use of standardised instruments
and definitions limited the extent to which this may have
happened. More than 80 % of the subjects fulfilled DSMIII-R criteria either for schizophrenia or for schizophreniform psychosis, and more than 90 % were classified in
classes S, P or O by the CATEGO.
Information on age at onset was obtained from the
key informants. The observed gender difference cannot
be attributed to differential misclassification due to recall
bias, and agrees with other studies. Observer bias might
have occurred in the assessment of mental state and social disability, but the practised use of standardized instruments makes this unlikely. The assessment of social
adjustment was not always blind to the assessment of psychopathology, but good inter-rater reliability observed
for the DAS suggests that there was no significant observer bias.
Discussion
Socio-demographic characwristics
About two-thirds of this consecutive sample of psychotic
patients admitted to psychiatric hospitals in a region of
Silo Paulo presented with Schneider's FRS, and almost
70 % fulfilled DSM-III-R criteria for schizophrenia. More
than 40 % had no income of any sort, depending entirely
on their relatives. Approximately half of the sample had a
poor social adjustment in the month prior to admission to
hospital. Men became ill at younger ages than females, but
there were no other gender differences in clinical features
or social adjustment. A specific finding was that subjects
not born in Sgo Paulo State showed more positive schizophrenic symptoms than those born in Silo Paulo state.
A recent survey on the prevalence of psychiatric disorders
in the community, which examined a representative
sample of the population of Silo Paulo, provided data on
socio-demographic and socio-economic characteristics of
that population (Mari and Andreoli 1990). Subjects included in the present study differed from the general
population in many ways. The proportion of single individuals was much higher in the study sample (65 % vs
33.3% in the general population). Low proportions of
married schizophrenics have been found in several studies
(Gmur 1991; Isele and Angst 1985; McGlashan 1984). The
study sample also had fewer years of education than the
general population, suggesting that people suffering from
schizophrenia have their educational development impaired by their illness. The disadvantages for subjects included in this study are also evident from occupational
status. Whereas more than half of the general population,
as assessed by the prevalence survey, were working regularly as employees or self-employed, less than 20 % of the
subjects in this study were doing so. In the general population 9 % were unemployed, contrasting with almost 30 %
of the study subjects. These findings are in accordance
with the results of several studies on schizophrenia
(Campbell et al. 1990; Isele and Angst 1985; McCreadie
1982; Mignolli et al. 1991; Tsuang and Fleming 1987).
Age mean (years)
Proportion male (%)
Mean age at onset (years)
Mean length of illness (years)
% S+
DAH mean
BSO mean
Place of birth
Silo Paulo
State
(n : 69)
32.6
53.6
23.8
8.9
56.5
9.0
4.5
Other
states
(n : 55)
32.5
46.4
25.0
7.5
76.4
12.6
5.5
P
0.90
0.61
0.65
0.27
0.021
0.017
0.31
Methodological limitations
This is a study of hospital-treated schizophrenia and excluded those not admitted to hospital; it is known that in
some countries some 20 % of all schizophrenic patients
do not receive hospital care (Westermeyer and Harrow
1988). Those aged 45 or over were also excluded from the
study, because it was designed to allow comparisons with
the W H O studies on schizophrenia. In fact, patients aged
45 or over accounted for about 20 % of all admissions due
to non-affective functional psychoses in the catchment
area during the study period. There were not cases under
the age of 18. One possible explanation is that local psychiatric hospitals admit only those aged 18 or over, with
the exception of the psychiatric ward in the general hospital, and patients with psychotic illnesses arising when
they are still under 18 years of age may seek treatment in
services outside the catchment area. The sample is not
representative of those schizophrenic patients with concomitant severe alcohol- or drug-related problems.
Symptomatology
The percentage of C A T E G O class S + observed in this
study is similar to those found in the three studies organized by the World Health Organization, the International Pilot Study of Schizophrenia (WHO 1973), the
W H O Collaborative Study on the Assessment and Re-
273
duction of Psychiatric Disability ( W H O 1988), and the
Determinants of Outcome of Severe Mental Disorders
(Jablensky et al. 1992). Almost two-thirds of the patients
presented with Schneider's 'first rank' symptoms, a figure
in agreement with those found in several studies in different settings (Carpenter and Strauss 1974; Ndetei 1988;
Wing et al. 1974).
underlying concepts and methodological shortcomings,
and an alternative explanation has been proposed, i.e.
that the association of migration with higher psychiatric
morbidity is confounded by the condition of being displaced from the labour forces (Almeida 1980). Further research specifically designed to investigate this issue is
needed.
Social disability
Conclusion
The higher adjusted scores in section 2 than section 1 of
the DAS indicate that subjects tended to have problems in
specific areas of behaviour, rather than in overall behaviour. In a study carried out in South Verona, Italy, dysfunctions in the sexual and occupational roles, items in
section 2, were more frequent than dysfunctions in the
items in section 1 (Mignolli et al. 1991). In the ' W H O Collaborative Study on the Assessment and Reduction of
Psychiatric Disability', 'sexual role' and 'work role' appeared to be altered first, whereas deterioration in 'selfcare' happened later ( W H O 1988). The same pattern was
also observed in a cohort of Dutch schizophrenics (de
Jong et al. 1985).
This is the first study carried out in Brazil in which a consecutive sample of hospital-treated schizophrenic patients
was assessed by means of standardised instruments. Results suggest that schizophrenic patients in a large urban
centre of Brazil share similar clinical features with patients from Western developed countries. The high proportion of patients without any kind of social security
benefits highlights the need of developing a proper social
security policy to guarantee even minimal living conditions for them.
Acknowledgements. Dr. R R. Menezes is supported by a grant from
the 'Conselho Nacional de Desenvolvimento Cientffico e Tecnoldgico-CNPq', Brazil. The authors thank M. Scazufca for her help with
DAS interviews, and Dr. K. Lloyd, Dr. H. Cope, and two anonymous
referees for their comments on earlier drafts of this paper.
Gender differences
The difference in educational level (men had more years
of formal education than women) follows the pattern
found for the general population (Mari and Andreoli
1990). Age at onset differed significantly between the
sexes. On average, men became ill 3.2 years earlier than
women, comparable with the 3.2-4.1 years observed by
Hafner et al. (1993), and within the range of differences
observed in the W H O Collaborative Study on Psychiatric
Disabilities (Hambrecht et al. 1992). This difference in
age at onset may be one of the reasons why there are more
men than women in this sample, since the maximum age
for entry in the study was set as 44 years, which might have
excluded women with later onset. Regarding symptomatology, there were only minor differences in accessory
symptoms, whereas for symptoms of nuclear schizophrenia there was no difference. This is in line with the findings
from the W H O multicentre study (Hambrecht et al. 1992)
in Western E u r o p e a n centres.
Place of birth
The present study was not originally designed to investigate the relationship between place of birth and schizophrenia, so that the finding that those not born in S~o
Paulo State have more positive schizophrenic symptoms
must be interpreted with caution. Some authors have suggested that immigration to large urban centres might be a
risk factor for the development of mental illness, especially in Latin American coutries, due to the stress of acculturation and cultural marginalisation (see Almeida
1985, 1987). However, studies carried out in Latin America focusing on this issue have been criticised for their
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Dr. P. Menezes
Section of Epidemiology and General Practice
Institute of Psychiatry
De Crespigny Park
London SE5 8AF
UK