Professor Luc Ciompi has argued that the benign course of schizophrenia in twentieth-century Switzerland may have been a result of the “exceptionally favorable socioeconomic conditions” that prevailed in that country throughout much of the century. He followed up more than 1,600 people with schizophrenia admitted throughout the century to the University Psychiatric Clinic in Lausanne until they passed the age of 65. Twenty-seven per cent had completely recovered and a further 22 per cent were only mildly disturbed. Thus, about half of the
patients had a favorable ultimate course of their illness.61 Such results are better
than average for the Western nations at that time or since. Were they a result of the full employment that had long existed in Switzerland? Unemployment there rarely reached one per cent in the decades following the Second World War, and through the 1960s and early 1970s was generally around a tenth of that figure. Even during the Great Depression Swiss unemployment did not scale the heights common throughout the rest of Europe.62As Professor Ciompi remarks:
If the socioeconomic condition in Switzerland did indeed exert a favorable influence on outcome, that would certainly be a highly significant finding. It would suggest that under favorable circumstances schizophrenia may run a predominantly favorable course.63
It would be equally significant if it could be shown that a benign course to schizophrenia was a by-product of the full employment that used to exist in planned socialist economies. The job security and the lower-intensity, slowerpaced labor process that were usual under socialist central planning64 could
have been particularly suitable for the rehabilitation of people with schizophrenia. In the USSR, continuous full employment existed from 1930 until the collapse of the communist regime. A right to work was recognized, and workers could expect jobs to be found for them even if they were barely productive.65 As the
mayor of Moscow pointed out on a visit to London in 1983, “It might be difficult for you to understand,…but one of the main issues we face in Moscow is the lack of labor hands in the city.”66 In Moscow, Leningrad and other large cities
at that time, vocational rehabilitation programs for the mentally disabled were highly developed and psychiatrists gave a great deal of attention to patients’ optimal work placement.67
In fact, outcome from schizophrenia in Moscow in the late 1960s was shown to be better than for patients in Western industrial countries. The WHO International Pilot Study of Schizophrenia is a large-scale, crossnational, collaborative project that was conducted simultaneously in nine countries in the West, in the Eastern Bloc and in the Third World. (This study will be discussed in more detail in the next chapter.) Patients with schizophrenia were selected from among those admitted to psychiatric centers in 1968 and 1969. On initial evaluation (as mentioned in Chapter 1) the groups of patients in most centers appeared to be comparable, but a standardized evaluation procedure showed that psychiatrists in Moscow and Washington, DC were using a broader, more inclusive diagnostic concept of schizophrenia. At two-year follow-up, overall outcome for the people with schizophrenia in Moscow was found to be better than for those admitted to the Western centers in London, Washington, DC and Aarhus (Denmark). Although relatively few of the Russian patients made a rapid and complete recovery (as can be seen in Table 7.2 in the next chapter), nearly half of these patients had a favorable outcome—that is, they had been non-psychotic for less than a year or had, at least, shown no serious social impairment for longer
than four months during the two-year follow-up period. By the same standardized follow-up criteria, only slightly more than a third of the patients in the centers in Britain, America and Denmark showed as great a degree of overall improvement. Substantially fewer of the Russian patients, further-more, were in the worst outcome category at follow-up.68 The superior recovery rates for
people with schizophrenia in Moscow may have been an artifact of the broader diagnostic approach there; yet a similarly inclusive diagnostic concept in Washington, DC, does not seen to have led to better outcome for the Americans with schizophrenia.
Recovery from schizophrenia in the WHO study was, however, no better in Prague (Czechoslovakia) than in the West, despite a labor shortage in Prague at that time. This difference between outcome in Moscow and Prague is difficult to explain. It may have been a result of the broader Russian diagnostic approach to schizophrenia. The year these patients were admitted to the study (1968) is the same year that the Warsaw Pact countries occupied Czechoslovakia, but it is not clear that this had an impact on the rehabilitation of people with schizophrenia. We can only say that the data so far available from full-employment societies are ambiguous, but that there is some evidence that such societies benefit from a more benign course to schizophrenia than is found in industrial nations with significant levels of unemployment.
We have gone a long way towards demonstrating that socio-economic conditions shape the course of schizophrenia. Outcome data on schizophrenia in the Depression, in the two sexes, in different social classes and in different political-economic systems all tend to support the notion that the effects of the labor market and, possibly, economic hardship are critical. In all of these instances the observed differences in the course of schizophrenia may be explained by both a direct effect of unemployment on the individual suffering from psychosis or by the influence of the demand for labor on rehabilitative and reintegrative efforts. In all these instances except one—the difference in recovery patterns for men and women—economic hardship may also be an important stress leading to relapse or poor outcome.
One further prediction remains to be examined—that if labor-market conditions can adversely affect the course of schizophrenia, the illness should be more benign in non-wage-labor settings. In the next chapter we will examine this possibility and, also, use the opportunity to study how major differences in political and domestic economy may affect the person with schizophrenia.
SUMMARY
• Spending on psychiatric hospital care increased during the Great Depression. • Spending on mental health services in Britain did not decline in the late
twentieth-century economic downturn when outcome from schizophrenia was worsening.
• The effect of both economic stress and unemployment on patients in the community could account for the decreased recovery rate from schizophrenia during the twentieth-century Great Depression.
• Many of the negative symptoms of long-term schizophrenia are identical with the psychological sequelae of long-term unemployment.
• Rehabilitative and reintegrative efforts for the mentally ill fluctuate with the business cycle and may contribute to changes in outcome in schizophrenia. • Females with schizophrenia achieve better outcome than men.
• People with schizophrenia from the lower social classes achieve worse outcome than higher-class patients.
• Outcome from schizophrenia in full-employment societies may be better than in other industrial nations.