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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 6 Epilepsy DEFINITION In recent epidemiological studies, epilepsy is defined by the recurrent presentation of two or more unprovoked seizures. This definition excludes single afebrile episodes, febrile seizures, and seizures that are manifestations of altered metabolic states, alcohol or drug withdrawal, and other transient cerebral insults.[1,2,3,4,5,6,7,8,9,10 and 11] The diagnosis of epilepsy thus defined is basically clinical, because no single laboratory test can confirm the absence of the condition. The test most commonly employed for the diagnosis of epileptic abnormalities is the electroencephalogram (EEG). While the EEG is a useful tool that can assist the clinician in arriving at a diagnosis of epilepsy, however, it is not always a sensitive or specific test.[3,4] Epilepsy manifests with several types of seizures, differing in age of onset, response to treatment, prognosis, electroencephalographic correlates, and risk factors. Moreover, epilepsy that is secondary to a parasitic infestation of the brain is a disorder altogether different from genetically determined epilepsies. Nonetheless, having a single term that encompasses all of these conditions makes it possible to calculate the burden of disease from both an economic and social perspective, to estimate the demand for health services planning, and to meet other public health objectives. The diagnostic classification standard currently in place for epilepsy was established by the International League Against Epilepsy in 1989 (see Box 6-1).
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World BOX 6-1 International Classification of Epilepsies and Epileptic Syndromes Localization-related (focal, local, partial) epilepsies and syndromes. 1.1 Idiopathic (with age-related onset) At present, the following syndromes are established, but more may be identified in the future: Benign childhood epilepsy with centro-temporal spike; Childhood epilepsy with occipital paroxysms; and Primary reading epilepsy. 1.2 Symptomatic: This category comprises syndromes of individual variability, based mainly on anatomical localization, clinical features, seizure types, and etiological factors (if known). 1.2.1 Epilepsy is characterized by simple partial seizures with the characteristics of seizures: Arising from frontal lobes; Arising from parietal lobes; Arising from temporal lobes; Arising from occipital lobes; Arising from multiple lobes; and Locus of onset unknown. 1.2.2 Characterized by complex partial seizures, that is, attacks with alteration of consciousness, often with automatisms; characterized by seizures: Arising from frontal lobes; Arising from parietal lobes; Arising from temporal lobes; Arising from occipital lobes; Arising from multiple lobes; and Locus of onset unknown. 1.2.3 Characterized by secondarily generalized seizures with seizures: Arising from frontal lobes; Arising from parietal lobes; Arising from temporal lobes; Arising from occipital lobes; Arising from multiple lobes; and Locus of onset unknown. 1.3 Unknown as to whether the syndrome is idiopathic or symptomatic. Generalized epilepsies and syndromes 2.1 Idiopathic (with age-related onset—listed in order of age) Benign neonatal familial convulsions; Benign neonatal convulsions; Benign myoclonic epilepsy in infancy; Childhood absence epilepsy (pyknolepsy); Juvenile absence epilepsy; Juvenile myoclonic epilepsy (impulsive petit mal); and Epilepsy with GTCS on awakening. Other generalized idiopathic epilepsies, if they do not belong to one of the above syndromes, can still be classified as generalized idiopathic epilepsies.
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 2.2 Cryptogenic or symptomatic (in order of age) West syndrome (infantile spasms, Blitz-Nick-Salaam Krampfe); Lennox Gastaut syndrome; Epilepsy with myoclonic-astatic seizures; and Epilepsy with myoclonic absences. 2.3 Symptomatic 2.3.1 Nonspecific etiology Early myoclonic encephalopathy 2.3.2 Specific syndromes Epileptic seizures may complicate many disease states. Under this heading are included those diseases in which seizures are a presenting or predominant feature. Epilepsies and syndromes undetermined as to whether focal or generalized 3.1 With bold generalized and focal seizures Neonatal seizures; Severe myoclonic epilepsy in infancy; Epilepsy with continuous spike waves during slow-wave sleep: and Acquired epileptic aphasia (Landau-Kleffner syndrome). 3.2 Without unequivocal generalized or focal features All cases with GTCS where clinical and EEG findings do not permit classification as clearly generalized or localization-related, such as in many cases of GTCS during sleep. Special syndromes 4.1 Situation-related seizures (Gelegenheitsanfalle) Febrile convulsions; Isolated seizures or isolated status epilepticus; Seizures occurring only when there is an acute metabolic or toxic event due to, for example, alcohol, drugs, eclampsia, nonketotic hyperglycemia, or uremia. Source:  SCOPE OF THE PROBLEM Among brain disorders, epilepsy stands out not only because of its high prevalence and incidence rates, but in particular because of the myths and beliefs attached to the condition in various cultures and the resulting impacts on the individual, the family, and the community.[15,16,17,18 and 19] More than 40 million people worldwide have been estimated to suffer from epilepsy, and an estimated 80 percent of those individuals live in developing countries.[5,13,19] Epilepsy commonly attacks young adults in the most productive years of their lives and frequently leads to unemployment, which often confounds the problems not only of the afflicted, but also of the family that relies on their financial support. Stigma and Discrimination Epilepsy remains among the most stigmatized brain disorders.[13,20] The associated stigma is more obvious in developing countries because of illiteracy
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World and misinformation regarding the actual nature of the condition. The shame and fear associated with the disorder prevent many affected individuals from seeking treatment. As a result, their epilepsy becomes uncontrolled, with consequences for education, employment opportunities, and social acceptance.[5,21,22] Children with epilepsy are removed from school and as adults lack the basic education needed for self-sufficiency.[22,23] Traditional medicines dispensed for epileptic seizures may be administered to children with febrile seizures with devastating consequences, such as oral burns and aspiration pneumonia. Those afflicted also frequently suffer crippling malformations or death due to burns, drowning, or other accidents. In Africa, for example, where open fires are used for cooking and heating, up to 30 percent of severe burns result from seizures. Because of the pervasive belief that epilepsy either is contagious or represents demonic possession, even family members may not act to pull these epilepsy sufferers from the flames.[18,26,27,28 and 29] Studies reveal that females with epilepsy are also less likely to marry and have children. Consequently, these women are rejected by their families and often left to means of survival that include prostitution, which significantly increases their vulnerability to many sexually transmitted diseases, particularly HIV/AIDS. Treatment Gap Even when proper medical treatment is sought and provided, patients do not recognize that long-term adherence to medications is required. The ensuing lack of adherence to treatment leads to seizure recurrences and a repetitive cycle of the social and physical burdens associated with the disorders. A treatment gap as high as 90 percent still affects many populations.[31,32] Other important factors contribute to the treatment gap, including cultural attitudes toward treatment, such as attributing the source of the illness to possession of the spirit or “the devil within.” Beliefs such as these provoke individuals to seek help from traditional healers and local religious figures [33,34 and 35] and do not lead them to effective medical treatments. Epidemiological studies reveal that the prevalence of epilepsy in developing countries is higher in rural than in urban populations. Reasons for this may include inadequate medical care facilities in remote areas for pregnancy control, safe delivery methods, early detection and treatment of childhood infections, and prompt and comprehensive health care. Cultural factors such as ignorance, fear, and rural illiteracy (higher than among urban populations) lead to a delay in seeking early diagnosis and treatment and compound the burden of epilepsy in these poorer regions. In developing countries, total earnings per capita per year amount to less than what one patient with epilepsy spends on treatment annually in developed countries. It has been calculated that the gross national product per capita of most developing countries barely suffices to buy a 2-year supply of
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World carbamazepine or valproic acid for one patient at the price at which it is sold in Europe. Therefore, monetary considerations often outweigh clinical judgment in therapeutic decisions. The availablity of anti-epileptic drugs (AEDs) in developing countries is limited because of poor drug production facilities and the inability of epilepsy sufferers to pay for the drugs. Indeed, it has been found that the developing countries, with 75 percent of the world's population, consume only 21 percent of the drugs produced globally, with drug consumption per capita being 12 times below that in the developed world. Notable defects of the drug distribution systems in developing countries include a lack of suitable storage facilities, logistic coordination, and transportation, and a lack of midlevel management skills in inventorying, ordering, and stock control. Poor quality control of domestically produced drugs may also be an important issue in developing countries. The problems of drug supply, coupled with inadequacies in the systems for delivery of health care, prevent many from receiving the care they need.[33,34] For more information on the costs of treating epilepsy see Appendix D. Infectious Diseases A multitude of infectious diseases are risk factors for epilepsy. Rates of prevalence for these diseases remain high in developing countries and contribute significantly to the higher prevalence of epilepsy in these regions as compared with developed countries.[ 6] Recommendation 6-1. To effectively address the needs of individuals with epilepsy and reduce the widespread stigma attached to the disease, national and local governments and health authorities of developing countries should support public education campaigns focused on the causes of epilepsy, the impact of the disease on the afflicted, and the availability of safe and effective treatments. Additionally, the rights of individuals with epilepsy under adequate treatment should be enforced to allow them equal access to employment, driving, and marriage. PREVALENCE AND INCIDENCE A number of recent neuroepidemiolgical studies provide fairly accurate data on the prevalence and incidence of epilepsy in various geographic regions of the world (see Table 6-2 and Table 6-3).[1,2,3 and 4,7,8,9,10 and 11,36,37,38,39,40 and 41] However, the comparability of these data is limited because of the lack of consistency in diagnostic definitions and methodology. Additionally, local variations in the prevalence of risk factors and genetic factors that may predispose individuals to develop epilepsy have undoubtedly contributed to the marked heterogeneity in epilepsy prevalence and incidence throughout the world.[11,40,41 and 42]
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World The available community-based prevalence data on epilepsy are rather consistent for industrialized countries. The prevalence rates range from 3.3/1000 population in England to 6.6/1000 in the United States.[ 17] Studies in developing countries reveal much higher rates: 17/1000 in Ecuador, 26–40/1000 in Liberia, and 20/1000 in Tanzania. The People's Republic of China (PRC) reports a rate of 4.6/1000  and some areas of Uganda have recorded rates as high as 57/1000.[ 44] A number of epidemiological studies have been conducted in India during the last three decades to determine the prevalence of epilepsy.[ 45,46] Careful scrutiny of the methodology and analysis of these studies reveals that 12 of them included house-to-house surveys with sound methodology and are comparable. The studies were conducted in various regions of India, representing populations from the north, south, east, and west of the country. They included both urban and rural populations. The prevalence rate of epilepsy was found to be 2.2 –9.0/1000 population. A recent house-to-house survey included a large sample (102,557) of Bangalore urban and rural populations and showed a prevalence rate of 8.8/1000. The prevalence rate in the rural population was 11.9/1000 and in the urban population was 5.7/1000, highlighting the fact that the prevalence of epilepsy is two-fold higher in rural than in urban populations. This large urban–rural difference calls for further case control studies to determine the risk factors involved, such as infections, trauma, obstetric practices, availability of health care facilities, and attitudes toward epilepsy. TABLE 6-1 Prevalence rate of epilepsy in Africa (per 1,000 inhabitants) Country Inclusion Criteria Prevalence Rate Sampling Size Method Burkina-Faso  RS 10.60 16,627 Community-based Ethiopia [49, 50] 5 (urban) 3,700 Community-based 8 (rural) Community-based 5.20 60,820 Community-based Ivory Coast  RS 7.60 1,176 Community-based Liberia [51, 52] RS 28.00 4,436 Community-based 43.00 2,733 Community-based Nigeria [37, 53, 54] 3.01 2,592 Community-based RS 37.00 903 RS + EEG 5.30 18,951 Senegal  Generalized seizures 3.10 35,219 Community-based South Africa  RS 0.22–2.20 50,000 Community-based 36,700 Mine workers Tanzania  RS 20.00 10,000 Community-based Togo RS + EEG 2.30 19,241 Community-based RS 19.8 9,143 Zimbabwe  7.40 17,500 Community-based
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World TABLE 6-2 Prevalence rate of epilepsy in Latin American countries Study Country Prevalence RateA Population Year Buenos Aires  Argentina 3.7 6,194 1995 Bogota  Colombia 19.5 8,970 1978 Cangahua  Ecuador 14.3 72,121 1984 Changuinola  Panama 57.0B 337 1988 Cordillera Province  Bolivia 24.5 10,000 1999 Coyocan  Mexico 16.0 1,013 1980 El Salvador  Chile 17.7B 17,694 1988 Marianoa  Cuba 7.5 14,445 1980 Medellin  Colombia 21.4 4,549 1988 Melipilla  Chile 27.6 2,085 1975 Migues  Uruguay 9.1 1,975 1990 Palugillo  Ecuador 22.6 221 1997 Porto Alegre  Brazil 16.5 1997 Quiroga  Ecuador 17.1 1,113 1985 Rural and urban population  Colombia 13.2 9,800 1991 Sao Paulo  Brazil 11.9 1986 Tecomatian  Mexico 25.0–41.6 360 1975 Tlalpan  Mexico 42.2 2,027 1976 V. del Cerro (present study)  Uruguay 11.5 21,186 1993 Viacha(33) Bolivia 26.2 1,183 1985 Z. Subtropical (23) Ecuador 16.6 1,382 1984 A Per 1,000 inhabitants; includes active and nonactive epilepsy B Includes only active epilepsy The prevalence of epilepsy in developing countries increases with age, reaching a peak in the third and fourth decades. It is interesting to note that in developing countries, the prevalence rate diminishes among those aged 60 and above. This fact may be explained by the increased mortality of patients with epilepsy, spontaneous remission, and the low survival of individuals with seizure disorders due to stroke and brain tumors. Only in Rochester, Minnesota, in the United States has the population above age 60 shown an increased prevalence rate, probably reflecting the improved medical care and follow-up of such individuals. As with the other age groups, the prevalence of epilepsy among children is highest in the most deprived areas of the world. Information on the incidence of epilepsy is widely available for developed countries, but the same information for developing countries is less complete. Reported figures range from 145/100,000 population per year for Japan [72,73]
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World to 48/100,000 per year in the United States. Rates ranging from 109—190/100,000 per year have been reported for Ecuador.[12,74,75] Rates in Africa have ranged from 64/100,000 in Ethiopia  to 156/100,000 in Uganda. Community-based surveys have proven to be an effective method for evaluating the magnitude and distribution of the disease.[15,16] However, the results of such surveys are influenced by local cultural factors. If epilepsy carries a social stigma, which is commonly the case, patients suffering from the condition will be hidden from researchers by family members. Because of the difficulties and the expense of implementing door-to-door surveys, increased attention is being focused on the use of key community informants to identify patients suffering from epilepsy.[41,76,77 and 78] This strategy was applied successfully, for example, in an urban marginal and rural region in Kenya. Mortality Rates It is well known that mortality data based on the single cause of death listed on a death certificate often underrepresent the number of deaths due to predicating conditions such as epilepsy. Case fatality rates for epilepsy are low in developed countries, so that mortality statistics are not a good indicator of the frequency of the disease.[ 4] A community-based study done in Ethiopia revealed that 6.3 percent of patients with epilepsy had died over a 2-year period as a results of complications from the disease. In Africa, epilepsy mortality has been shown to be related to status epilepticus, falls, drowning, suicide, and burns. More research is needed to adequately understand this aspect of epileptic disease burden. RISK FACTORS Data collection on the epidemiology, etiology, and natural history of epilepsy have increased understanding of this devastating disease. Many of the risk factors for epilepsy have been identified, and understanding of their relative contribution to epilepsy incidence continues to improve.[19,80,81,82,83 and 84] It will be important for the development of efficacious and comprehensive programs for the prevention and treatment of epilepsy to further investigate and identify risk factors in developing country populations. More recently, researchers have emphasized the importance of studying risk factors separately according to the different epilepsy types. It has also been stressed that taking into account the age of onset of epileptic disorders will increase study group homogeneity, therefore increasing the potential for identifying specific risk factors.[ 12,74,85,86]
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Genetic The risk of epilepsy is increased three-fold for individuals who have a first-degree relative with the condition. In addition, a number of diseases that follow Mendelian patterns of inheritance may have seizures as one of their manifestations or their only manifestation. In many developing countries, consanguinity is relatively common. Such practices are likely to increase the risk of seizure disorders in any offspring. In isolated communities, specific inherited diseases may contribute to the etiology of epilepsy, as is the case in the Grand Bassa Country of Liberia and among the Wapagoro tribe in Tanzania.[43,88] However, a studied conducted in the Parsi community of Bombay showed no significant association between consanguinity and epilepsy despite the high frequency of consanguinious marriages. Pre-, Peri- and Post-Natal In a community-based study in Ecuador, significant risk factors for epilepsy starting before age 20 were found to be a positive family history (genetic factors), prematurity, perinatal hypoxia, sleep disorders in the first 3 months of life, and febrile seizures; for epilepsy starting at age 20 and above, only prematurity was found to be a significant risk factor. When the analysis was done according to seizure type, it was found that for generalized seizures, family history and febrile convulsions were significant risk factors, whereas for partial seizures, family history, prematurity, perinatal hypoxia, and sleep disorders were statistically significant factors.[12,74] Perinatal hypoxia is associated with epilepsy in developing countries as it relates to maternal and childhood malnutrition. In an Ecuadorean study, calculation of the population rate difference percentage suggested that programs aimed at controlling both prematurity and perinatal hypoxia could decrease the number of epilepsy cases by 42 percent.[ 12,74] In the PRC, carefully designed epidemiological studies found that the following were significant risk factors for idiopathic epilepsy: premature or difficult birth, maternal disease during pregnancy, febrile convulsions, family history for epilepsy, and maternal age above 30.[2,84] In Nigeria, the putative risk factors for epilepsy were found to be febrile convulsions, malnutrition, maternal alcohol consumption, and lack of immunizations.[37,83] In developed countries, where acquired epilepsy constitutes about 40 percent of all cases, perinatal pathology is reported to be the cause of around 14 percent of all epilepsies. In developing countries this figure should be higher, although there are no good community-based studies to provide such data. The causes of perinatal hypoxia include maternal cardiovascular disease, placental and umbilical cord disorders, prolonged labor, and airway obstruction at birth. In dystocic deliveries, the excessive reduction of fetal cranial diameter may lead to herniation of hippocampal regions through the tentorium, causing
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World ischemia, atrophy, and subsequent gliosis of these structures (mesial sclerosis). These conditions in turn predispose to epilepsy and can now easily be visualized by magnetic resonance of the brain in individuals thus affected.[11,86,87] In many developing countries, most deliveries in rural areas are performed by traditional birth attendants. Complications with delivery are common, and the incidence of preterm deliveries is at least twice that in developed countries. Mothers in developing countries are frequently malnourished, anemic, and exposed to a variety of infections that could affect the baby in utero or at delivery and increase the risk for epilepsy.[19,86] Parasitic Infections Neurocysticercosis is caused by Taenia solium (more commonly known as tapeworm). This disease may account for up to two-thirds of late-onset epilepsy (epilepsy starting above age 20) in geographic regions in Africa, Asia, and Latin America in which this infection is endemic.[90,91,92,93,94,95,96,97 and 98] Rapid control of transmission of T. solium taeniosis from animal to human may be attained through a vaccine that renders pigs immune to cysticercosis. (Additional information on neurocysticercosis as a risk factor for epilepsy and the implications for prevention and treatment can be found in Annex 6-1.) Paragonomiasis, caused by the parasite Paragonimus westermani, is endemic to Asia, particularly Korea, Japan, the Philippines, and China, as well as some parts of Africa and South America. Epileptic seizures, usually focal motor, are a common manifestation of this condition.[11,100,101] Schistosomiasis can also induce seizures. This is the case particularly with S. japonicum infections, and less commonly with S. mansoni and S. haematobium infections. Acute schistosomiasis may produce a serious encephalopathy with coma, papilledema, and partial or generalized seizures. Chronic forms of cerebral schistosomiasis, caused by embolized schistosoma eggs, are commonly manifested in epileptic attacks. Congenital toxoplasmosis, acquired during pregnancy, induces seizures in 40–60 percent of affected children, who may display mental retardation and blindness as well.[103–104] Toxoplasmosis is also a frequent opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS), inducing seizures in about 25 percent of affected individuals. African trypanosomiasis, or sleeping sickness, is caused by T. brucei, and is widely distributed through sub-Saharan Africa. The chronic stage of the disease is characterized by progressive neurological involvement, including partial and generalized seizures. Chagas disease, caused by T. cruzi, is a public health problem in rural areas of Central and South America. Cerebral involvement is secondary to embolization of the parasite and manifests itself as a late-onset epilepsy, involving mainly partial seizures.
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Malaria is endemic to tropical Africa, Latin America, and Asia. Epilepsy is a late sequela of this common disease. Status epilepticus has been reported to occur in up to 13.6 percent of malaria cases. One-third of these occurrences are due to infection with Plasmodium falciparum, which produces the dreadful cerebral malaria.[87,105] Epilepsy can also be a rare manifestation of other parasitic infections of the central nervous system, such as sparganosis [108,109] and onchocerciasis.[44,110,111] Bacterial Infections Tuberculous meningitis is highly prevalent in urban marginal and poor rural areas of most developing countries, but it is particularly important in Asia and certain African countries.[112,113 and 114] This infection can cause epilepsy as a late sequela in 8–14 percent of affected patients. Intracranial tuberculomas can present as space-occupying lesions and seizures.[115,116 and 117] Pyogenic meningitis is also a common infection in the tropics, and epidemics of meningococcal meningitis occur periodically in Brazil and sub-Saharan Africa. In the United States, the overall risk for epilepsy was found to increase seven-fold among 734 survivors of intracranial infections; for individuals with a diagnosis of brain abscess, the risk was more than 40 times greater. The risk for epilepsy remains elevated in patients who have suffered from meningeal infections for at least 20 years after the illness. Viral Infections Japanese encephalitis is perhaps the most important and best-documented form of epidemic viral encephalitis in developing countries.[119,120 and 121] Bangladesh, India, Nepal, Thailand, and Vietnam are the most affected areas. Epilepsy is a frequent manifestation, found in 1–20 percent of survivors.[122,123] Human immunodeficiency virus (HIV) is often accompanied by seizure disorders. Up to 60 percent of patients with HIV in Africa have been diagnosed with epilepsy. The rising epidemic of HIV/AIDS in Africa may soon be the leading cause of seizure disorders. Head Injuries In the United States severe head trauma accounted for 12 percent of epilepsy cases. Annegers et al. found the risk slightly higher at 17.2 percent.[ 126] Head trauma related to road traffic accidents or violent assault is a very common cause of epilepsy in Brazil and Uruguay.[103,127] Occupational hazards and accidental falls due to poor safety conditions may also result in head injuries.[128,129,130 and 131] Head trauma is a preventable condition, and campaigns to
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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Summary of Findings: Schizophrenia in Developing Countries The average lifetime risk of schizophrenia is about 1 percent. Compared to its incidence and prevalence, the social and economic costs of schizophrenia are disproportionately high. The condition causes greater chronic disability than any other mental disorder, in part because of its early age of onset and the stigma of “insanity.” In both developed and developing countries, schizophrenia is associated with excess mortality from a variety of causes associated with poor self-care, inadequate nutrition, heavy smoking, and medical neglect. At least part of this excess mortality is preventable. A high proportion of better outcomes for schizophrenia in developing countries has been reported by numerous investigators. The reasons for this are unknown, but may involve interactions between specific genetic and environmental factors. Research on this topic could have fundamental implications for the management and treatment of schizophrenia in both developing and developed countries. Schizophrenia and other psychotic illnesses can be controlled with a variety of treatments that offer significant returns in terms of symptom improvement, quality of life, and reintegration into the community. The choice of an antipsychotic therapeutic agent, however, must involve a balance between several potentially conflicting factors: clinical efficacy, profile and incidence of adverse effects, acceptability and likelihood of treatment adherence, and cost-effectiveness.
Representative terms from entire chapter: