Prevalences of Schizophrenia, Bipolar Disorder, and Depressive Disorders in Community between Taiwan and Other Countries

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1 Overview Taiwanese Journal of Psychiatry (Taipei) Vol. 26 No Prevalences of Schizophrenia, Bipolar Disorder, and Depressive Disorders in Community between Taiwan and Other Countries Yi-Hong Yang, M.D. 1,2,5*, Eng-Kung Yeh, M.D. 3,4,5,6, Hai-Gwo Hwu, M.D. 5,6,7,8,9 This overview was intended to re-analyze and compare the findings from the Taiwan Psychiatric Epidemiological Project (TPEP) with those from the other studies conducted in 11 sites with different ethnic and cultural backgrounds. In 1980s, all these studies used criteria from American Psychiatric Association s Diagnostic and Statistical Manual of Mental Disorder, Third Edition (DSM-III), Diagnostic Interview Schedule (DIS) in their case identification tool and the identical sampling methods. Taiwan, Hong Kong and a part of Shanghai, China, had significantly lower lifetime prevalence rates (LPRs) for schizophrenia, bipolar disorder and depressive disorders than South Korea and all countries with non-eastern cultural backgrounds. Although more genetic and biological studies are needed to explain the lower prevalences of schizophrenia and bipolar disorder, we speculate that the cultural and family systems in Taiwan provide protecting effects on those two disorders. Key words: DSM-III mental disorders in community, schizophrenia, bipolar disorder, depressive disorders (Taiwanese Journal of Psychiatry [Taipei] 2012; 26: 77-87) Introduction Comparison of cross-national or cross-cultural study on a specific disorder can shed light on understanding its protective and risk factors, etiology, clinical course and outcome. For instance, if the prevalence of a certain disorder is similar between different societies and cultural environments, this may indicate that sociocultural factors have little influence on that disorder. But on the other hand, significant difference in the prevalence of a certain disorder in different societies and cultural environments suggests that differences in the sociocultural environment may have major influence on the disorder apart from the differences in 1 Department of Psychiatry, Yang-Ming Branch, Taipei City Hospital 2 Graduate School and Department of Psychology and Counseling, National Taipei University of Education 3 Department of psychiatry, Shin-Kong Wu Ho-Su Memorial Hospital 4 Department of Psychiatry, Taipei Medical University Hospital 5 Department of Psychiatry, National Taiwan University Hospital 6 Department of psychiatry, College of Medicine, National Taiwan University 7 Graduate Institute of Brain and Sciences, College of Medicine, National Taiwan University 8 Department of Psychology, College of Science, National Taiwan University 9 Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University Received: January 15, 2012; revised: February 13, 2012; accepted: February 13, 2012 Corresponding author. No. 105, Yu-Sheng St., Taipei 111, Taiwan Yi-Hong Yang <yihong49@ yahoo.com.tw>

2 78 Schizophrenia, BD, Depressive Disorders in the Community genetic factors. While cross-national studies on the etiology as well as protective and risk factors of specific mental disorders are important issues, many factors, especially inconsistencies in research methods and definitions of disorders exist to make this kind of comparative studies more difficult. Examples of these factors, such as diagnostic criteria, case identification tools, sampling methods, sample size, refusal of recruitment rates, reliability of interviewers, statistical tools, differences in languages and cultural backgrounds, etc. may influence the results of epidemiological study on mental disorders. The main objectives of this study were (A) to review the literature from the major epidemiological studies of community population with the identical sampling and case-identifying methods towards the DSM-III; and (B) to compare the findings from Taiwan Psychiatric Epidemiologic Project (TPEP) with those from other countries with non-eastern cultural backgrounds and with other sites with Eastern cultural backgrounds. Reanalyzing those old data, we hoped that the results of this study would help understand the risk and protecting effects of socioeconomic and cultural living environment on the prevalence of specific mental disorders in respective sites. Special emphasis was made to compare the findings between Taiwan and those areas with Eastern cultural backgrounds such as Hong-Kong, China, and South Korea to help understand the effects of different sub-cultural and social living environment on the expression and prevalences of specific mental disorders within the areas with Eastern culture. Comparison of Taiwan and the U.S. As shown in Table 1, Compton et al. compared the findings from the TPEP with that of Table 1. Lifetime prevalence rates (%) of specific mental disorders in Taiwan and the US DSM-III Diagnosis Taiwan Unweighted % SE affected No. U.S. Unweighted affected No. % SE Any diagnosis < Major depression <10 56 Dysthymic disorder <10 12 Manic disorder Alcohol abuse/dependence <10 47 Drug abuse/dependence < Antisocial personality disorder <10 45 Cognitive impairment Schizophrenia <10 9 Schizophreniform disorder Generalized anxiety disorder Panic disorder <10 16 Phobic disorder <10 88 Obsessive-complusive disorder <10 23 Somatization disorder Adapted from Compton et al., 1991 [1] Z P

3 Yang YH, Yeh EK, Hwu HG 79 Epidemiologic Catchment Area (ECA) survey after weighting the TPEP samples against the ECA samples. This study discovered that, except two common disorders, generalized anxiety disorder (GAD) and somatization disorder, which showed no significant difference in the life time prevalence rates (LPRs), all the other mental disorders were significantly less prevalent in Taiwan than in the U.S. The LPRs of any diagnosis including all mental disorders in the Taiwan sample were 21.56%, while those in the U.S. sample were 35.55% [1]. Cross-National Collaborative Group (CNCG) Study of Four Specific Mental Disorders Table 2 shows the one-year prevalence rates (one-year PRs) and LPRs of four specific mental disorders in ten countries. After weighing population characteristics in different countries, Weissman et al. discovered that the prevalences of major depressive disorder (MDD) differed greatly between respective countries [2-5]. For instance, Table 2. One-year and lifetime prevalence rates (%) of four types of mental disorders in respective countries in the CNCG study a U.S. Canada Puerto Rico France West Germany Italy Lebanon Taiwan South Korea New Zealand Major depression* Male Female Total 5.2 (3.0) 9.6 (5.2) 4.3 (3.0) 16.4 (4.5) 9.2 (5.0) (0.8) 2.9 (2.3) 11.6 (5.8) Remission rate Bipolar disorder * Male Female Total Remission rate Panic disorder* Male Female Total 1.7 (1.0) 1.4 (0.9) 1.7 (1.1) 2.2 (0.9) 2.6 (1.7) 2.9 (1.3) 2.1 (2.1) 0.4 (0.2) 1.7 (1.5) 2.1 (1.3) Remission rate Obsessive-compulsive disorder** Male Female Total 2.3 (1.3) 2.3 (1.4) 2.5 (1.8) (1.6) (0.4) 1.9 (1.1) 2.2 (1.1) Remission rate Bipolar disorder included persons who ever had a full manic episode,whether depression had ever been diagnosed. * Ages 18 to 64 years ** Ages 26 to 64 years ( ) One-year prevalence rate a Weissman MM et al., 1994, 1996, 1997 [3-5]

4 80 Schizophrenia, BD, Depressive Disorders in the Community the one-year PRs of MDD varied from 0.8% in Taiwan to 5.8% in New Zealand, and LPRs ranged from 1.5% in Taiwan to 16.4% in France and 19.0% in Lebanon. This study also found that the LPRs of MDD were unanimously higher in females than in males in all countries, and that the mean ages of onset of MDD were similar in all countries (between 24.8 years and 34.8 years). The comorbidity rates of MDD and substance use disorder and anxiety disorders were relatively high in all countries. The LPRs of MDD were significantly higher among persons with broken marriages (separated or divorced) than among nonbroken married persons in most countries. Weissman et al. inferred that the large differences among the LPRs of MDD in different countries might be related with the effects of different cultures, or other possible risk factors which were reflected on the expression of depressive symptoms respectively. In contrast, LPRs of bipolar disorder were similar in all countries, but was still lowest in Taiwan (0.3%), and were generally similar in males and females; the age of onset of bipolar disorder was generally six years younger than that of MDD. The LPRs of panic disorder were higher in females than males in all countries, and the mean ages of onset are generally similar in all countries, between 23.2 years and 35.5 years. One-year PR (0.2%) and LPR (0.4%) are relatively lower in Taiwan than those in the other countries. The LPRs of obsessive-compulsive disorder (OCD) were almost similar in males and females in all countries except in New Zealand where the rate was higher in females, and the mean ages of onset were similar in all countries (between 21.9 years and 35.5 years). Although the one-year PRs and LPRs of OCD were close in all countries, both one-year PR (0.4%) and LPR (0.7%) were still relatively lower in Taiwan. Weissman, et al. indicated that the reasons that the one-year PR and LPR of MDD, bipolar disorder, panic disorder, and OCD in Taiwan were persistently lower than in other countries remained to be clarified [2-5]. Comparisons among the Pacific Rim Countries Hwu compared TPEP data with other Eastern culture, South Korea and those with different cultures including the U.S., with mixed Caucasian and African-American cultures, countries with Caucasian cultures, Canada and New Zealand, and a Hispanic culture, Puerto Rico [6]. He found that Eastern cultures had lower LPRs of mental disorders than the U.S., Caucasian, and Hispanic cultures. Greater variation was found in the LPRs of mental disorders in urban samples than in rural samples in all countries, which indicated that the stage of urban development had a significant influence on the prevalence rates of mental disorders in different cultures. Hwu also found that the LPRs of mental disorders in urban samples from the Chinese cultural areas of Taipei, Hong Kong and Shanghai were uniformly lower than those in South Korea and countries with Western cultural backgrounds. For mental disorders, Hong Kong was found to have higher LPRs than Taipei, while Taipei had higher LPRs than Shanghai. Hwu inferred that degree of modernization might have different effects on the LPR of mental disorders [6]. This study took TPEP as the reference to compare with the studies from other 11 sites with Eastern and non-eastern cultural backgrounds which used the identical study methods. The TPEP had its particular importance and value in the history of epidemiological studies of community population because this was the first trial to use the structural interview schedule as a case finding tool to reach the DSM-III diagnoses through computer programs in Taiwan. Therefore, the findings

5 Yang YH, Yeh EK, Hwu HG 81 Table 3. Demographic characteristics in 12 respective sites Taiwan d Hong South New Puerto West China b U.S. a Canada a France a Kong c Korea a Zealand a Rico a Germany a Italy a Lebanon a Target population 1,670, ,304 5,000,000 13,520,908 1,198, , ,000 1,792,127 16,239 29,240,900 1,000,000 16,750 Sample Nos studied 11,004 7,229 3,098 5,100 18,571 3,258 1,498 1,513 1, , Response rate (%) Female (%) Age at interview (%) y 25 * y 43 * y 24 * y * Age groups in Hong Kong are y, y and y a Weissman MM et al., 1996 [4] b Wang CH et al., 1992 [30] c Chen CN et al., 1993 [27] d Hwu HG et al., 1986 [34] could be used to compare with those of the ECA conducted in the U.S. and the other sites using the similar methods. The respective studies subject to compare or discuss in this study included Taiwan (TPEP) [7], South Korea (Korea Epidemiological Study of Mental Disorders) [8, 9], Canada (Edmonton Survey of Psychiatric Disorders) [10, 11], the U. S. (ECA) survey [12-14], Puerto Rico (Puerto Rico Study of Psychiatric Disorders) [15], West Germany (Munich Follow-up Study) [16, 17], France (French Study of Psychiatric Disorders) [18-20], Italy (Florence Community Survey of Mood Disorders) [21-23], Lebanon (Beirut War Events and Depression Study) [24], New Zealand (Christchurch Psychiatric Epidemiology Study) [25, 26], Hong Kong (Shatin Community Mental Health Survey) [27] and China (Shanghai Psychiatric Epidemiological Survey) [28-30], The diagnostic criteria, structural interview schedules, sampling methods, and the training methods of layman interviewer used in each site were reasonably consistent; and the surveys were all conducted during the 1980s. Since the DIS in the U.S. and other English-speaking countries, and also its translated forms in non-english-speaking countries had shown to yield satisfactory validity and reliability, it was considered to be a reliable case identification instrument that was well-suited for this comparative study [31-36]. We analyzed the data with odds ratio (OR) and Fisher s exact test. The level of significance was set at p < 0.05 (two tailed). Table 3 shows the demographic characteristics of the samples in the respective 12 sites. Response rate referred to the number of people who answered the survey divided by the number of people in the sample. Though the response rates ranged from 63% to 100% among the different sites, the male/female ratios of the population were fairly similar. The Hong Kong sample used an age group classification that is different from those used in the other sites. Comparisons among Taiwan and Countries with Non- Eastern Cultural Backgrounds Table 4 compares the prevalence rates of four specific mental disorders in Taiwan with those in

6 82 Schizophrenia, BD, Depressive Disorders in the Community Table 4. Lifetime prevalence rate (%) of specific mental disorders in Taiwan and countries with non-eastern cultural backgrounds Schizophrenia Bipolar disorder MDD Dysthymic disorder Taiwan U.S a 0.37 b 5.2 a a OR and 95%CI (3.62; ) (2.16; ) (4.11; ) (3.03; ) p-value < < < < Canada c OR and 95%CI (2.26; ) (3.57; ) (7.04; ) (3.47; ) p-value < 0.05 < < < New Zealand d OR and 95%CI (0.98; ) (3.89; ) (10.81; ) (6.16; ) p-value 1.00 < 0.05 < < West Germany e OR and 95%CI (2.30; ) (1.20; ) (7.35; ) (3.70; ) p-value < < Puerto Rico f OR and 95%CI (5.90; ) (3.07; ) (3.63; ) (4.43; ) p-value < < 0.05 < < a Compton III WM et al., 1991 [1] b Weissman MM et al., 1994, 1996, 1997 [3-5] c Bland RC et al., 1988 [11] d Wells JE et al., 1989 [25] e Wittchen HU et al., 1984 [32] f Canino GJ et al., 1987 [15] the U.S., Canada, New Zealand, West Germany, and Puerto Rico. Schizophrenia and bipolar disorder Table 4 shows that the LPR of schizophrenia was significantly lower in Taiwan than in the U.S., Puerto Rico (p < 0.001), and Canada (p < 0.05), and the LPR of bipolar disorder was also significantly lower in Taiwan than in the U.S., Canada (p < 0.001), New Zealand and Puerto Rico (p < 0.05). Depressive disorders The LPR of MDD was significantly lower in Taiwan than in the U.S., Canada, New Zealand, West Germany, Puerto Rico (p < 0.005) and the LPR of dysthymic disorder was again significantly lower in Taiwan than in the U.S., Canada, New Zealand, West Germany and Puerto Rico (p < 0.001). Comparisons among Taiwan and Countries with Eastern Cultural Backgrounds Table 5 compares the LPRs of four specific mental disorders in Taiwan and other sites with Eastern cultural backgrounds. Schizophrenia and bipolar Disorder The LPR of schizophrenia was significantly higher in Taiwan than in Hong Kong (p < 0.05),

7 Yang YH, Yeh EK, Hwu HG 83 Table 5. lifetime prevalence rates (%) of specific mental disorders in Taiwan and sites with Eastern cultural backgrounds Schizophrenia Bipolar disorder MDD Dysthymic disorder Taiwan Hong Kong a OR and 95%CI (0.46; ) (0.88; ) (1.48; ) (1.82; ) p-value < < 0.05 < China b OR and 95%CI (0.71; ) (0; ) (0.15; ) (0.26; ) p-value 0.55 < 0.05 < < South Korea c OR and 95%CI (1.37; ) (2.51; ) (2.61; ) (2.04; ) p-value 0.29 < < < a Chen CN et al., 1993 [27] b Wang CH et al., 1992 [30] and fairly comparable with that in China and South Korea. The LPR of bipolar disorder in Taiwan was fairly comparable with that in Hong Kong, significantly higher than that in China (p < 0.05), and significantly lower than that in South Korea (p < 0.001). The LPR of bipolar disorder was in general lower in sites with ethnic Chinese cultural backgrounds than in South Korea. Depressive disorders The LPR of MDD in Taiwan was significantly higher than that in China (p < 0.001), but significantly lower than that in Hong Kong (p < 0.05) and South Korea (p < 0.001). These rates were unanimously lower in sites with Chinese cultural backgrounds than that of South Korea. The LPR of dysthymic disorder in Taiwan was significantly higher than that in China (p < 0.001), significantly lower than those in Hong Kong, and South Korea (p < 0.001). These rates were uniformly lower in sites with Chinese ethnic cultural backgrounds than in South Korea. Remission Rates Remission is defined as meeting criteria for a lifetime diagnosis but not suffering from the disorder during the year prior to the interview [37]. The remission rate is estimated by the difference between LPR and one-year PR divided by the LPR. Table 2 shows the remission rate that we estimated from the data of CNCG study. The remission rate for MDD was 46.7% in Taiwan. The remission rates for MDD were between 40% to 50% around in the vast majority of countries. It indicated that an average of around one-half of MDD cases took chronic courses. This problem was severest in South Korea where the remission rate was only 20.7%, and mildest in France with 72.6%. Schizophrenia and bipolar disorder The LPRs of schizophrenia were significantly lower in Taiwan, Hong Kong and China than those of all countries with non-chinese cultures except New Zealand, West Germany, South Korea. The LPR of bipolar disorder were again signifi-

8 84 Schizophrenia, BD, Depressive Disorders in the Community cantly lower in Taiwan, Hong Kong and China than in countries with non-chinese cultural background except West Germany. Among the Eastern areas, the rates of bipolar disorder were significantly lower in sites of Chinese background than South Korea. It was noteworthy to find that the LPRs of these two major psychotic disorders, schizophrenia and bipolar disorder, in Taiwan had been fairly stable in the past three nationwide epidemiologic studies of community population over the past six decades after the World War II in spite of the tremendous demographic and socioeconomic changes associated with drastic changes in political situation, rapid industrialization and globalization in Taiwan. The first study, the Formosan Study, was conducted during by the three-steps census survey of all inhabitants in the target communities [38]. The second one was the follow-up study of the first one, 15 years later during by the same investigators [39], and the third one, the TPEP during the 1980s [7]. It can be speculated that at least in Taiwanese community population, the prevalence rates of these two major psychiatric disorders are perhaps more associated with genetic and biological factors than social and environmental factors, and that the cultural values and social systems in Taiwan have had protecting effect on the prevalence of these two disorders. Whether this speculation is suitable suitabk for Hong Kong and China, needs more systemic and carefully designed follow up study in each site, respectively. The mortality rate of schizophrenia was found to be higher than that of general population in Taiwan [40, 42], and was reported with further decreasing rate after Mental Health Act came in force in 1991 [43]. We can also expect that rate of schizophrenia will be even lower because of the improved care since the execution of Taiwan National Health Insurance in But in the long-term studies in Taiwan showed the similar result except the Formosa follow-up study that revealed lower LPR. The phenomenon indicates that lower LPR of schizophrenia may be due to lower incidence, not related to socioeconomic change. Depressive disorders The LPR of MDD was significantly lower in Taiwan than in countries with ethnic non-chinese cultures. Some countries with high LPR of MDD had been known to have sources of psychosocial stress. Lebanon endured constant strife since the time of 1975s civil war until the research survey year of 1990s [36]. Since residents were under severe, long-term stress and strain throughout this period, the high rate of MDD was not surprising. According to Karam et al. s tracking study employing the DIS/DSM-III-R diagnostic standards excluding combatants, female community residents had a LPR of MDD as high as 30%, while this rate in males was 20% [24]. This clearly indicated that psychological stress was certainly even severer among noncombatant females than it was among combatant males. The LPR of MDD among the residents of the Ain Remmaneh district of the embattled city of Beirut was as high as 41.9%, and here the main source of psychosocial stress included physical injury and ruin of homes [24]. The Canadian city of Edmonton changed rapidly from an agricultural community to an industrial metropolis city following the discovery of petroleum. The economic foundation of the New Zealand city of Christchurch shifted from farming and ranching to tourism and commerce; France s Savigny underwent a transformation from a farming to an industrial town; Italy s Florence was evolved from a center of art and culture into a commercial and tourist town. The high LPRs of MDD in these areas might be associated with the

9 Yang YH, Yeh EK, Hwu HG 85 degree and speed of socioeconomic changes and the residents acculturation. There were large differences in the LPRs and remission rates of MDD in different countries. It can therefore be inferred that social and living environment are factors that may influence the MDD prevalence. The LPRs of MDD and dysthymic disorder were lower in Taiwan than in all other sites except China. The LPRs of MDD and dysthymic disorder were relatively low in sites with ethnic Chinese cultural backgrounds. A possible reason for Taiwan s low LPR of depressive disorders, notwithstanding Taiwan s relatively great social and cultural changes, was the protective effects of the traditional cultural values of family and social systems [44. 45]. Yeh et al. found that the traditional cultural values of the strong family s interdependence, and its direct and/or buffering effects at the time of stressful life events were significantly associated with the lower rate of depressive symptoms in Taiwan community population [46]. Another reason for Taiwan s low LPR of depressive disorders maybe anxiety or somatic symptoms replace depressive symptoms. The low genetic virulence hypothesis as a possible factor for low prevalence rate of depressive disorders needs further studies to clarify. Limitations of the Reviewed Data The readers should not over-interpret the data in this study because this study has three major limitations. First, all data in this overview were collected in 1980s and not updated. They may not reflect what is happening. Second, all epidemiologic data were mainly collected from questionnaire of interview schedules rather the direct clinical interview on the patients by certified psychiatrists. And third, we do not have any longitudinal studies on a cohort of patients or community habitants to ascertain the stability of persons under study. Conclusion Taiwan, Hong Kong and China had significantly lower LPRs for schizophrenia, bipolar disorder and depressive disorders than most countries with non-chinese cultural backgrounds. Traditional Chinese cultural value, particularly its family systems in Taiwan, Hong Kong, and probably also in China seems to provide significantly the protecting effects on the prevalences of schizophrenia, bipolar disorder and depressive disorders. We suggest that at least in Taiwanese societies the prevalences of schizophrenia and bipolar disorder are perhaps more related to genetic and biological factors than social and environmental factors, but that the cultural and social systems in Taiwan have protecting effects on the prevalences of these two disorders. References 1. Compton III WM, Helzer JE, Hwu HG, et al.: New methods in cross-cultural psychiatry: psychiatric illness in Taiwan and the United States. Am J Psychiatry 1991; 148, 12: Cross-National Collaborative Group: The changing rate of major depression. JAMA 1992; 268: Weissman MM, Bland RC, Canino GJ, et al.: The cross national epidemiology of obsessive compulsive disorder. J Clin Psychiatry 1994; 55 (Suppl 3): Weissman MM, Bland RC, Canino GJ, et al.: Crossnational epidemiology of major depression and bipolar disorder. JAMA 1996; 276: Weissman MM, Bland RC, Canino GJ, et al.: The cross- national epidemiology of panic disorder. Arch Gen Psychiatry 1997; 54: Hwu HG: Prevalence of psychiatric disorders defined by Diagnostic Interview Schedule: international

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