The family economic status and outcome of people with schizophrenia in Xinjin,Chengdu,China: 14-year follow-up study

Abstract

Background:

Little is known about whether family economic status might influence the long-term (e.g. over 10 years) outcome of persons with schizophrenia in the community.

Aim:

To examine the differences in outcome at 14-year follow-up of persons with schizophrenia from high versus low family economic status backgrounds in a Chinese rural area.

Method:

A prospective 14-year follow-up study was conducted in six townships in Xinjin County, Chengdu, China. All participants with schizophrenia (n = 510) were identified in an epidemiological investigation of 123,572 people aged 15 years and older and followed up from 1994 to 2008.

Results:

Individuals from low family economic status (<mean) in 1994 had significantly higher rate of homelessness (9.9%) and lower rate of survival (63.8%) in 2008 than those from high family economic status (⩾mean; 3.2% and 76.6%, respectively). Individuals from low family economic status had significantly lower rates of marriage and complete remission, higher mean scores on Positive and Negative Syndrome Scale (PANSS) and lower mean score on Global Assessment of Functioning (GAF) than those from high family economic status in 2008. The predictors of low family economic status of individuals in 2008 encompassed the baseline low family economic status, poor families’ attitude toward the patient, younger age, older age of first onset and longer duration of illness.

Conclusion:

Low family economic status is a predictive factor of poor long-term outcome of persons with schizophrenia in the rural community. Individuals’ family economic status should be considered in making mental health policy and providing community-based mental health services.

Keywords

Family economic status poverty schizophrenia outcome China

Introduction

The relationship between poverty and mental health held great interest for both health and economic policy makers in the past two decades (Lund et al., 2011). Growing international evidence indicates that mental ill health and poverty interact in a negative cycle within low- and middle-income countries (LMICs) (Lund et al., 2011; Patel et al., 2010). Socioeconomic deprivation and family socioeconomic status (SES), associated with biological and environmental experiences, are identified as an important cause and consequence of common mental disorders including schizophrenia (Agerbo, Byme, Eaton, & Mortensen, 2004; Agerbo et al., 2015; Patel & Kleinman, 2003; Ran et al., 2004; Werner, Malaspina, & Rabinowitz, 2007; Xiang et al., 2008). Limited availability of financial resources, access to health care, limited social networks and increased discrimination can adversely affect the course and outcome of mental illness (Cohen, 1993; Link & Phelan, 1995; Livingston & Boyd, 2010; Ran, Xiang, Huang, & Shan, 2001; Samele et al., 2001). While there has been increasing interest in the impact of poverty on disability, relatively fewer studies have examined the effects of SES on mental health outcomes (Brown, Susser, Jandorf, & Bromet, 2000; Ucok, Polat, Cakir, & Genc, 2006).

Despite the majority of individuals with schizophrenia residing in LMICs, the impact of poverty on course of schizophrenia is not well-studied in this context (Lund et al., 2011). The link between SES and outcome in schizophrenia has been examined primarily in high-income countries, and these studies were limited by their cross-sectional or short-term follow-up design (Smith et al., 2006; Xiang et al., 2008). Few longitudinal follow-up (e.g. over 10 years) studies have been conducted to explore the precise causal mechanisms between SES and outcome of schizophrenia (Lund et al., 2011). It is still unknown whether low family economic status or relative poverty (the level of income in relation to the mean or median income of a population) has an impact on the long-term outcome of persons with schizophrenia in the community (Toye & Infanti, 2004).

There are two main theories to explain the possible causal relationship between SES and schizophrenia-related outcomes. The social causation hypothesis proposes lower SES to be a cause of poorer schizophrenia-related outcomes (Hollingshead & Redlich, 2007). However, the social selection hypothesis suggests that schizophrenia hinders the individuals’ ability to move up or stay in the same social class (Dohrenwend et al., 1992; Saraceno, Levav, & Kohn, 2005). It has been suggested that the social selection hypothesis might be more applicable to schizophrenia (Saraceno et al., 2005). However, more studies, especially longitudinal follow-up studies, are needed to test whether the social selection hypothesis is more applicable to schizophrenia.

With China’s rapid social and economic development since the early 1990s, the social and economic change may have a potential influence on mental health (Lee et al., 2007). Are persons with schizophrenia at increased risk of drifting into or remaining in poverty, as shown within a long-term follow-up paradigm? This longitudinal study provides a unique opportunity to examine whether lower family economic status at an earlier time is linked with 14-year follow-up outcomes in persons with schizophrenia within the rapidly transforming socioeconomic context of rural China.

The objectives of this 14-year prospective follow-up study were as follows: (1) to examine whether poor SES predicts worse longitudinal outcomes at 14-year follow-up, (2) to explore whether the percentage of families with low family economic status at follow-up when compared to baseline may remain the same or increase and (3) to define the predictors of long-term low family economic status in persons with schizophrenia.

Method

Study population

This is one of studies in the Chengdu Mental Health Project (CMHP) in Chengdu, China (Ran, Mao, Chan, Chen, & Conwell, 2015; Ran, Weng, et al., 2015). All subjects with schizophrenia (n = 510) were identified from an epidemiological investigation of 123,572 people aged 15 years and older in six townships of Xinjin County in March 1994. Subjects were identified through screening procedures using the Psychoses Screening Schedule (PSS) for psychosis (face-to-face interviews with the head of each household together with the key informant method) and general psychiatric interview. Key informants were cadres or leaders of local villages. General psychiatric interview was completed with subjects by trained psychiatrists. The details of this investigation have been described in previous publications (Ran et al., 2001; Ran et al., 2004; Ran et al., 2009; Ran et al., 2015). In brief, all subjects lived in rural communities and met International Classification of Diseases, Tenth Revision (ICD-10) criteria (WHO, 1992) for a diagnosis of schizophrenia based on standardized administration of the Present State Examination (PSE-9) by trained research interviewers (Ran et al., 2001). Based on the baseline data in 1994, we successfully followed up and interviewed 98.0% (total 500 cases) of subjects with schizophrenia and/or all their key informants 10 years later (May 2004) and 95.9% of the subjects (total 489 cases) and/or all their key informants 14 years later (June 2008; Ran et al., 2009; Ran, Mao, et al., 2015). The average net income of resident in rural Xinjin was 6,417 RMB per year in 2008. The study was approved by the University Committee on Human Research Subjects (CHRS) and all respondents gave informed consent at each stage of the study.

Measurement

The principal assessment tools included the PSE and Social Disability Screening Schedule (SDSS) in the baseline investigation in 1994 (Ran et al., 2001; Ran et al., 2004). The Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) were also used in 2008 (Ran, Mao, et al., 2015). For subjects alive at the follow-ups in 2004 and 2008, at least one person familiar with each subject’s life and circumstances and the subjects themselves were interviewed. For deceased subjects, the next-of-kin or at least one person familiar with the subject was interviewed. All the interviews were conducted by trained psychiatrists using the Patients Follow-up Schedule (PFS) in 2004 and 2008 (Ran, Mao, et al., 2015). The PFS was used to collect information concerning demographic characteristics, causes and time of death, clinical symptoms, treatment information, criminal behavior, social functioning and social support. For all subjects, medical and psychiatric treatment records were ascertained from hospital, village doctors’ clinics and traditional healers. For deceased subjects, information from the death certification and suicide note, where applicable, was also obtained.

The classification of each death as due to suicide, accident or natural causes represented the consensus opinion of interviewers and independent researchers after reviewing all information obtained during the interviews. Subjects were defined as homeless and lost to follow-up if informants reported that they had wandered and slept in public places and that their whereabouts, at the time, were unknown. Subjects were defined as without caregiver if they had no person (e.g. family member or others) to provide care (e.g. food, housing, financial support and treatment). Family economic status/level (e.g. above or below the average (mean) annual income of household in the same local area at the same period in time) was defined according to the informants’ reports. Criminal behavior (e.g. theft, physical and sexual assault behaviors and murder) was defined according to subjects’ and informants’ report (e.g. relatives).

Statistical analysis

We explored the link between baseline assessment (1994) and later evaluations (2004 and 2008) for family economic status and other variables. Family economic status differences during the follow-up period (1994, 2004 and 2008) were assessed via comparing the demographic, psychological and social environment characteristics of family economic status (⩾mean level and <mean level). A chi-square (χ²) or Fisher’s exact test was used to assess the significance of the differences in categorical data, and independent sample t-tests (two-tailed) were used to compare between-group continuous factors. The effects of family economic status on survival and suicide rates were tested using univariate Cox hazard regression analyses. A logistic regression model (stepwise) was used to analyze the factors associated with the low family economic level in 2008. The family economic status (low: <mean level or high: ⩾mean level) in 2008 was considered the dependent variable, while all the other variables from 1994 evaluation (baseline data) were the independent variables. Statistical analyses were performed using SPSS Windows software (version 20.0).

Results

Of the 510 person identified as having schizophrenia at baseline in 1994 (Ran et al., 2009; Ran, Mao, et al., 2015), 10 were excluded in 2004 and 21 were excluded in 2008 due to loss to follow-up; therefore, 500 subjects (98.0%) and 489 subjects (95.9%) were followed up in 2004 and 2008, respectively. Informants were available for all these subjects (100%). In 2008, information on 300 subjects was provided by both subjects and their informants, and information on 189 subjects was provided by their informants alone.

Current status of the cohort

Table 1 shows the status of the participants in 2008. The rate of survival was significantly lower in the low family economic status group (<mean level; 63.8%) than the high family economic status group (⩾ mean level; 76.6%; p < .01). The survival rate in high family economic status group was significantly higher than that in low family economic status group using Cox hazard regression analyses (hazard ratio (95% confidence interval (CI)): 0.613 (0.410–0.917); p < .05). There was no significant difference in suicide rate between low and high family economic status groups using Cox hazard regression analyses. The rate of homelessness was significantly higher in the low family economic status group (9.9%) than the high family economic status group (3.2%; p < .05). There were no significant differences in suicide and deaths due to other causes between these two groups.

Table 1.

Status of the cohort patients in 2008.

	Family economic status⩾Mean level, N (%)	Family economic status<Mean level, N (%)	Total (N = 489), N (%)
Survivals	95 (76.6)	233 (63.8)**	328 (67.1)
Deaths
Suicide	3 (2.4)	21 (5.8)	24 (4.9)
Death due to other causes	22 (17.7)	75 (20.5)	97 (19.8)
Homelessness	4 (3.2)	36 (9.9)*	40 (8.2)

df: degree of freedom.

p < .05 (Fisher’s exact test); **χ² = 6.86, df = 1, p < .01.

Change in family economic status from 1994 to 2008

Table 2 shows the change in family economic status during the 14-year follow-up. The rate of low family economic status (<mean level) significantly increased from 49.7% in 1994 to 71.0% in 2008 (p < .001). The rate of high family economic status (⩾mean level) significantly decreased from 50.3% in 1994 to 29.0% in 2008.

Table 2.

Change in family economic status during the 14-year follow-up.

	Family economic status in 2008 (surviving cases)		Total
	⩾Mean level, N (%)	<Mean level, N (%)	Total
Family economic status in 1994
⩾Mean level	67 (70.5)	98 (42.1)***	165 (50.3)
<Mean level	28 (29.5)	135 (57.9)	163 (49.7)
Total	95 (29.0)	233 (71.0)	328 (100)

df: degree of freedom.

***

χ² = 21.88, df = 1, p < .001.

Characteristics of surviving participants in 1994, 2004 and 2008

Table 3 shows the characteristics of surviving participants in 1994, 2004 and 2008. Compared with persons with high family economic status, persons from low family economic status were more likely to be single and live alone, had fewer numbers of family members, lower rate of having a family caregiver and had poorer familial attitudes toward the patient. Moreover, persons with low family economic status had significantly poorer mental status (e.g. lower rates of partial and complete remission), higher rates of being unable to work, lower mean GAF scores and higher mean PANSS scores (positive score, negative score, general mental score and total PANSS score) than those with high family economic status.

Table 3.

Characteristics of surviving participants in 1994, 2004 and 2008.

	1994 (n = 510)		2004 (n = 372)		2008 (n = 328)
	⩾Mean level (n = 232), n (%)	<Mean level (n = 278), n (%)	⩾Mean level (n = 167), n (%)	<Mean level (n = 205), n (%)	⩾Mean level (n = 95), n (%)	<Mean level (n = 233), n (%)
Gender, male	94 (40.5)	143 (51.4)*	62 (37.1)	97 (47.3)*	34 (35.8)	96 (41.2)
Marital status, married	192 (82.8)	176 (63.3)***	127 (76.1)	111 (54.2)***	71 (74.7)	138 (59.2)**
Education (⩽primary school)	164 (70.7)	208 (74.8)	114 (68.3)	146 (71.2)	58 (61.1)	172 (73.8)*
Family history of psychosis	65 (28.0)	80 (28.8)	46 (27.5)	63 (30.7)	32 (33.7)	61 (26.2)
Live alone	9 (3.9)	55 (19.8)***	10 (6.0)	55 (26.8)***	7 (7.4)	42 (18.0)*
With family caregiver	211 (90.9)	209 (75.2)***	162 (97.0)	174 (84.9)***	93 (97.9)	215 (92.3)*
Families’ attitude toward patient (maltreatment)	52 (22.4)	108 (38.8)***			8 (9.2)	66 (29.6)**
With criminal behavior	8 (3.4)	10 (3.6)			7 (7.4)	31 (13.3)
Suicide attempts	21 (9.1)	16 (5.8)	29 (17.4)	32 (15.6)	21 (22.1)	48 (20.6)
Mental status
Full remission	86 (37.1)	39 (14.0)***			36 (37.9)	56 (24.0)***
Partial remission	40 (17.2)	28 (10.1)			32 (33.7)	39 (16.7)
Marked symptoms/deteriorated	106 (45.7)	211 (75.9)			27 (28.4)	138 (59.2)
With antipsychotic medication	178 (76.7)	197 (70.9)	127 (76.0)	152 (74.1)	72 (75.8)	167 (71.7)
With previous hospitalization	55 (23.7)	55 (19.8)	58 (34.7)	65 (31.7)	38 (40.0)	82 (35.2)
Inability to work	40 (17.2)	76 (27.3)**	22 (13.2)	62 (30.2)***	15 (15.8)	79 (33.9)**
	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)
Age (years)	45.3 (16.6)	44.0 (14.5)	53.4 (13.8)	51.3 (13.0)	56.7 (13.2)	55.8 (12.7)
Number of family members	3.9 (1.3)	3.1 (1.6)***	3.7 (1.5)	2.6 (1.3)***	3.8 (1.7)	3.0 (1.5)***
Duration of illness (years)	11.6 (11.3)	13.2 (11.2)	21.5 (10.7)	21.7 (10.8)	25.7 (11.8)	25.3 (10.6)
Age of first onset (years)	31.8 (14.2)	30.4 (11.9)	30.6 (12.2)	28.4 (10.8)	29.5 (10.8)	29.2 (11.0)
Total positive score (PANSS)					10.4 (5.3)	12.8 (6.1)**
Total negative score (PANSS)					11.6 (5.9)	17.0 (9.7)***
Total general mental score (PANSS)					22.6 (8.1)	27.1 (9.6)**
Total score (PANSS)					46.8 (16.2)	59.9 (22.6)***
Total score of GAF					75.1 (18.6)	56.0 (24.8)***

SD: standard deviation; PANSS: Positive and Negative Syndrome Scale; GAF: Global Assessment of Functioning.

p < .05; **p < .01; ***p < .001.

Predictors of family economic status of participants in 2008

Table 4 shows the multivariate mode of predictors of low family economic status of participants in 2008 (logistic regression analyses). Five factors were identified as significantly independent predictors of the low family economic status of participants in 2008: low family economic status, poor families’ attitude toward the patient, younger age of patient, longer duration of illness and older age of first onset in 1994.

Table 4.

Predictors of poor family economic status of participants in 2008.

	Wald	OR	95% CI	p
Lower family economic status in 1994	13.692	2.878	1.644–5.039	.001
Poor families’ attitude toward the patient	6.703	3.427	1.349–8.709	.010
Older age (years)	6.568	0.930	0.879–0.983	.010
Longer duration of illness (years)	5.316	1.064	1.009–1.121	.021
Older age of first onset (years)	4.708	1.061	1.006–1.119	.030
Higher education level	3.792	1.877	0.996–3.538	.051
Larger number of family members	3.648	0.824	0.675–1.005	.056

OR: odds ratio; CI: confidence interval.

Family economic status was collected in 2008, and all independent variable data were collected in 1994.

Discussion

To our knowledge, this is the first 14-year prospective cohort study examining the relationship between family economic status and outcome in people with schizophrenia in a rural community. This study arguably contributes the most rigorous empirical data to the existing knowledge of the relationship between family economic status and long-term outcome of persons with schizophrenia in LMICs. The strengths of this study include the use of a large representative community sample in rural China, its longitudinal 14-year follow-up data and high rates (>95%) of participant retention.

Change in family economic status

Despite rapid development in the national economy (e.g. gross domestic product (GDP)) in China during the past two decades, this study demonstrated that participants’ family economic status significantly declined during the 14-year follow-up. A substantial proportion of individuals from families with high or average family economic status at the beginning of the study (50.3%) transitioned to low family economic status at the end of the study (71.0%; p < .001). Although family economic status in this study reflects the relative family economic status, findings suggest that the family economic status of persons with schizophrenia will decline gradually with the longer duration of illness. This may partly be due to the inability of families of persons with schizophrenia to catch up with the broader growth in the country.

Family economic status and outcome of participants

The results of this study demonstrated that persons with schizophrenia in low family economic status during the 14-year follow-up period had a significantly higher rate of homelessness and lower rate of survivals than those in high family economic status, which is consistent with previous studies examining SES and schizophrenia outcomes (Brown et al., 2000). Persons with low family economic status had significantly higher rates of living alone, being unmarried, having less number of family members than those with high family economic status, which is in agreement with previous studies (Agerbo et al., 2004; Thara, Kamath, & Kumar, 2003; Xiang et al., 2008). Consistent with previous research (Ran, Mao, et al., 2015; Ran, Weng, et al., 2015), we found male participants to have a significantly lower family economic status than female participants in 1994 and 2004, but not in 2008. Our previous study also indicated that a low family economic status was related to the never-treated status in 1994 (Ran, Mao, et al., 2015; Ran, Weng, et al., 2015). While there were no significant differences in the rates of antipsychotic medication and hospitalization between high and low family economic status groups, this may be related to (1) the lower rates of antipsychotic medication and hospitalization in persons with schizophrenia in both high and low family economic status in rural China and (2) the higher rate of homelessness and lower rate of survivals in low family economic status group (Ran et al., 2001; Ran et al., 2004; Ran, Mao, et al., 2015; Ran, Weng, et al., 2015). Persons with schizophrenia who had received no antipsychotic medication or hospitalization had significantly higher rates of homelessness and mortality (Ran et al., 2009; Ran, Weng, et al., 2015). Our findings support that low family economic status in rural China may place persons with schizophrenia and their families at greater vulnerability to the social and economic costs of severe mental illness and make them experience a worsening in family economic status over time.

Previous studies indicate that low family economic status or relative poverty is a major determinant of poor outcome (e.g. clinical symptoms, social functioning) in persons with schizophrenia (Ran et al., 2011; Smith et al., 2006; Ucok et al., 2006; Zipursky, 2014). The results of this study also showed that persons with schizophrenia with low family economic status or relative poverty had poor mental status, higher scores of PANSS and poor social functioning than those with high family economic status. Our findings indicate that low family economic status or relative poverty may cause poor long-term outcome (e.g. progressive decrease in family economic status, poor clinical symptoms, social functioning) among persons with schizophrenia.

The possible reasons for poor outcomes in persons with low family economic status in the 14-year follow-up may include the following: (1) poor mental health services (e.g. lack of mental health professionals, limited community mental health care) and increased health expenditure making it difficult for accessing necessary treatment for persons with schizophrenia, especially those with low family economic status. As mental health care is typically not covered under standard health insurance products in China, persons with schizophrenia and their family have to pay for the mental health services in rural areas, thus making it more difficult for persons with schizophrenia from low family economic status to access health services (e.g. medication, hospitalization) and maintain treatment (Lund et al., 2011; Ran et al., 2001; Ran et al., 2004; Ran, Weng, et al., 2015). (2) Poor family support and care (e.g. lower rates of marriage and having a family caregiver, less numbers of family members and higher rate of living alone). In general, traditionally supportive family networks are crucial for providing emotional and economic support for persons who suffer from mental illness (Ran et al., 2001; Ran et al., 2003). For families with patients, especially patients with chronic mental illness from low family economic status in rural China, access to social network resources may be much more restricted (L. H. Yang & Kleinman, 2008). (3) Psychiatric stigmatization and discrimination prevent persons with psychiatric disorders from attending mental health services in China (Phillips, Li, Stroup, & Xin, 2000; L. H. Yang et al., 2014). Low income has been found to be associated with increased frequency of stigma experiences and negative social and psychological consequences for individuals with psychosis (Dickerson, Sommerville, Origoni, Ringel, & Parente, 2002; Livingston & Boyd, 2010). (4) Loss of employment and associated earning for persons with mental illness and their families (Saraceno et al., 2005). (5) Lack of decent and safer housing and improved nutrition (Ran et al., 2001; Ran et al., 2004; Zipursky, 2014). Living in poor or unstable housing situations may further limit the level of social support, ability to access adequate treatment and opportunities for recovery (Ran et al., 2004; Zipursky, 2014), so households are unable to financially accommodate a family member experiencing severe and chronic mental illness (e.g. schizophrenia).

When interpreting the overall study findings via frameworks conceptualizing the relationship between SES and schizophrenia, the findings in this study provide greater support for social selection hypothesis. Our findings showed that there were no differences in family history of psychosis between low and high family economic status groups. The percentage of families with low family economic status increased significantly during the 14-year follow-up. Moreover, the poorer 14-year outcome (e.g. clinical symptoms, social functioning) was predicted by lower family economic status. The results of this study suggest that schizophrenia hinders the individuals’ ability to move up or stay in the same social class (i.e. lower SES might be a consequence of schizophrenia; Dohrenwend et al., 1992; Saraceno et al., 2005). Poor outcomes at the end of 14-year follow-up may suggest that failure to cope with the social and occupational demands leads to a downward move to lower socioeconomic levels (Chen et al., 1998).

Predictors of the low family economic status in the 14-year follow-up

Why have patients with schizophrenia remained or become poorer in terms of family economic status in the 14-year follow-up? The results of this study indicated that the main predictors of the low family economic status of individuals with schizophrenia in 2008 included baseline low family economic status, poor families’ attitude toward the patient, younger age, longer duration of illness and older age of first onset in 1994. Younger age of patients may cause family economic burden for a longer time. Older age of first onset may indicate that more persons with schizophrenia who are family economic earners may suffer from schizophrenia. Poor families’ attitude toward the patient may influence the families’ ability of money earning and family economic status. Longer duration of illness is a predictor of low family economic status which may suggest that the traditionally supportive family network may be broken down by prolonged illness and patients’ poor clinical status (Ran et al., 2004). The longer duration of illness of persons with schizophrenia, the higher level of family economic burden and the less ‘filial piety’ the individual with schizophrenia may be able to provide.

Implications for policy and services

Our findings have particular relevance for people with schizophrenia in a country such as China, which has experienced rapid economic development during the past two decades. While economic change has increased the nation’s overall wealth and status, development has not been equally distributed, particularly in rural areas. Our study findings among rural persons with schizophrenia demonstrate an overall decline in SES by the majority of persons with schizophrenia and their families. According to the World Bank, China’s Gini index, a measure of the extent of which the distribution of income or consumption expenditure among individuals or households within an economy deviates from a perfectly equal distribution, escalated from 35.5 in 1993 to 42.6 in 2008 which implies inequality (World Bank Development Research Group, 2015). This increasing wealth gap in China predominantly comprises the differences between rural and urban regions (Sicular, Yue, Gustafsson, & Li, 2007). Policies favor urban areas to develop economically at a faster rate than rural areas (D. T. Yang, 1999). While migration by rural laborers to work in urban areas and remittance back to their rural families have worked to somewhat mitigate rural versus urban economic differences (i.e. household income in rural areas have increased per capita from 8.5% to 13.1%), the poorest rural households often do not have members who migrate to urban areas (Du, Park, & Wang, 2005). Schizophrenia causes large economic burden among patients and their family members. While rural contexts may provide some accommodation for work (L. H. Yang et al., 2013; L. H. Yang et al., 2014), the majority of persons with schizophrenia in our study reported inability to participate in full-time work. Thus, it is crucial to emphasize the financial support for persons with schizophrenia, especially regarding accessing mental health services in rural China.

This study captures a unique aspect of China’s economic experience among Chinese rural persons with schizophrenia during rapidly transforming economic times. How can we break the negative cycle of mental ill health and poverty? First, national policies that aim to break the cycle of poverty and mental illness are crucial (Lund et al., 2011). Specific health policy should be developed for people with mental disorders who need to be targeted for development assistance (World Health Organization (WHO), 2010). Second, given the possibility of mental health interventions of addressing the social selection or social drift pathway for improving clinical status thereby leading to better mental health, high-quality mental health interventions are needed to address both the social causes of mental illness along with disabilities and economic deprivation (Lund et al., 2011; Ran, Chan, Ng, Guo, & Xiang, 2015; Ran et al., 2003). Moreover, mental health interventions should be emphasized in development of Chinese mental health services. Our findings highlight marginalized groups who might disproportionately experience poor mental health and remain in grave need for intervention at the individual and policy level. Third, necessary supports (e.g. disability income support, health insurance, community mental health care, vocational training and support, decent and safe housing and family support) should be provided to people with schizophrenia, especially those with a chronic illness living in a low family economic status (Zipursky, 2014). Our study provides a strong basis for addressing issues of poverty for individuals with schizophrenia and their family members, which we strongly recommend to develop health policy on social welfare and mental health interventions (e.g. community mental health services, family intervention) and to improve outcomes for persons with schizophrenia (Ran, Chan, et al., 2015). Fourth, mental health should become integrated as a central element of monitoring the outcomes of poverty alleviation programs (Lund et al., 2011). Further research should be conducted on poverty alleviation programs.

Given the representativeness of the sample used in the 14-year follow-up study, we suggest that our findings are generalizable to the population of people with schizophrenia in rural areas, and even possibly other LMICs that have a similar social and economic environment. Family income may be much more relevant to LMICs than other settings where persons with mental disorders rely on alternative support systems. Overall, family economic status or relative poverty and the long-term outcome of persons with schizophrenia are serious concerns in rural China and other similar LMIC settings.

Limitations of the study

The limitations of this study include the possible recall bias for interviews with subjects and informants at long-term follow-up intervals, but such bias may be minimized by the use of multiple follow-up data sources. The cohort in this study included all persons with schizophrenia (old and new patients) in 1994. The death and suicide rates may be underestimated because most homeless individuals were lost to follow-up. Only the overall family economic status was considered in the study. Given the diversity of sociocultural, economic and care provision characteristics, the results of this rural China study may not generalize to urban areas and high-income countries.

Footnotes

Acknowledgements

The authors thank the Xinjin Mental Hospital and the Chengdu Mental Health Center for collaboration and data collection.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The 1994 Chengdu study was supported by a grant from the China Medical Board in New York (CMB, 92-557; MZ Xiang, PI). This study was supported in part by Global Research Initiative Program from National Institutes of Health (NIH; 1R01 TW007260-01; M.S Ran, PI), American Foundation for Suicide Prevention (AFSP; M.S Ran, PI) and Contemporary China Seed Funding Award (CCSFA, HKU; MS Ran, PI).

References

Agerbo

Byme

Eaton

W. W.

Mortensen

P. B.

(2004). Marital and labor market status in the long run in schizophrenia. Archives of General Psychiatry, 61, 28–33.

Agerbo

Sullivan

P. F.

Vilhjálmsson

B. J.

Pederson

C. B.

Mors

Børglum

A. D.

… Mortensen

P. B.

(2015). Polygenic risk score, parental socioeconomic status, family history of psychiatric disorders, and the risk for schizophrenia: A Danish population-based study and meta-analysis. JAMA Psychiatry, 72(7), 635–641.

Brown

A. S.

Susser

E. S.

Jandorf

Bromet

E. J.

(2000). Social class of origin and cardinal symptoms of schizophrenic disorders over the early illness course. Social Psychiatry and Psychiatric Epidemiology, 35, 53–60.

Chen

C. H.

Shen

Y. C.

Zhang

W. X.

S. R.

Huang

Y. Q.

Wang

J. R.

… Meng

G. R.

(1998). Epidemiological survey on schizophrenia in 7 areas of China. Chinese Journal of Psychiatry, 31(2), 72–74 (in Chinese).

Cohen

C. I.

(1993). Poverty and the course of schizophrenia: Implications for research and policy. Hospital & Community Psychiatry, 44, 951–958.

Dickerson

F. B.

Sommerville

Origoni

A. E.

Ringel

N. B.

Parente

(2002). Experiences of stigma among outpatients with schizophrenia. Schizophrenia Bulletin, 28, 143–155.

Dohrenwend

B. P.

Levav

Shrout

P. E.

Schwartz

Naveh

Link

B. G.

… Stueve

(1992). Socioeconomic status and psychiatric disorders: The causation-selection issue. Science, 255, 946–952.

Park

Wang

(2005). Migration and rural poverty in China. Journal of Comparative Economics, 33, 688–709.

Hollingshead

A. B.

Redlich

F. C.

(2007). Social class and mental illness: A community study 1958. American Journal of Public Health, 97, 1756–1757.

10.

Lee

Tsang

Zhang

M. Y.

Huang

Y. Q.

Y. L.

Liu

Z. R.

… Kessler

R. C.

(2007). Lifetime prevalence and inter-cohort variation in DSM-IV disorders in metropolitan China. Psychological Medicine, 37, 61–71.

11.

Link

B. G.

Phelan

(1995). Social conditions as fundamental causes of disease. Journal of Health and Social Behavior, 35(Extra Issue), 80–94.

12.

Livingston

J. D.

Boyd

J. E.

(2010). Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Social Science & Medicine, 71, 2150–2161.

13.

Lund

De Silva

Plagerson

Cooper

Chisholm

Das

… Patel

(2011). Poverty and mental disorders: Breaking the cycle in low-income and middle-income countries. The Lancet, 378, 1502–1514.

14.

Patel

Kleinman

(2003). Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization, 81, 609–615.

15.

Patel

Lund

Hatherill

Plagerson

Corrigall

Funk

Flisher

A. J.

(2010). Mental disorders: Equity and social determinants. In Blas

Kurup

S. A.

(Eds.), Equity, social determinants and public health programmes (pp. 115–134). Geneva, Switzerland: World Health Organization.

16.

Phillips

M. R.

Stroup

T. S.

Xin

(2000). Causes of schizophrenia reported by patients’ family members in China. British Journal of Psychiatry, 177, 20–25.

17.

Ran

M. S.

Chan

C. L. W.

Chen

E. Y. H.

Mao

W. J.

S. H.

Tang

C. P.

… Conwell

(2009). Differences in mortality and suicidal behaviour between treated and never-treated persons with schizophrenia in rural China. British Journal of Psychiatry, 195, 126–131.

18.

Ran

M. S.

Chan

C. L. W.

S. M.

Guo

L. T.

Xiang

M. Z.

(2015). The effectiveness of psychoeducational family intervention for patients with schizophrenia in a 14-year follow-up study in a Chinese rural area. Psychological Medicine, 45, 2197–2204.

19.

Ran

M. S.

Chen

E. Y.

Ran

B. Y.

Tang

C. P.

Lin

F. R.

… Hu

S. H.

(2011). Risk factors for poor work functioning of persons with schizophrenia in rural China. Social Psychiatry and Psychiatric Epidemiology, 46, 1087–1093.

20.

Ran

M. S.

Mao

W. J.

Chan

C. L. W.

Chen

Conwell

(2015). Gender differences in outcomes in people with schizophrenia in rural China: 14-year follow-up study. British Journal of Psychiatry, 206, 283–288.

21.

Ran

M. S.

Weng

Chan

C. L. W.

Chen

E. Y. H.

Tang

C. P.

Lin

F. R.

… Xiang

M. Z.

(2015). Different outcomes of never-treated and treated patients with schizophrenia: 14-year follow-up study in rural China. British Journal of Psychiatry, 207, 495–500.

22.

Ran

M. S.

Xiang

M. Z.

Chan

C. L. W.

Leff

Simpson

Huang

M. S.

… Li

S. G.

(2003). Effectiveness of psychoeducational intervention for rural Chinese families experiencing schizophrenia: A randomised controlled trial. Social Psychiatry and Psychiatric Epidemiology, 38, 69–75.

23.

Ran

M. S.

Xiang

M. Z.

Conwell

Lamberti

J. S.

Huang

M. S.

Shan

Y. H.

X. Z.

(2004). Comparison of characteristics between geriatric and younger patients with schizophrenia in community. Journal of Psychiatric Research, 38, 417–424.

24.

Ran

M. S.

Xiang

M. Z.

Huang

Shan

(2001). Natural course of schizophrenia: 2-year follow-up study in a rural Chinese community. British Journal of Psychiatry, 178, 154–158.

25.

Samele

van Os

McKenzie

Wright

Gilvarry

Manley

, … UK700 Group. (2001). Does socioeconomic status predict course and outcome in patients with psychosis? Social Psychiatry and Psychiatric Epidemiology, 36, 573–581.

26.

Saraceno

Levav

Kohn

(2005). The public mental health significance of research on socio-economic factors in schizophrenia and major depression. World Psychiatry, 4, 181–185.

27.

Sicular

Yue

Gustafsson

(2007). The urban–rural income gap and inequality in China. Review of Income and Wealth, 53, 93–126.

28.

Smith

Malla

Williams

Kopala

Love

Balshaw

(2006). The Canadian national outcomes measurement study in schizophrenia: Overview of the patient sample and methodology. Acta Psychiatrica Scandinavica, 113(Suppl. 430), 4–11.

29.

Thara

Kamath

Kumar

(2003). Women with schizophrenia and broken marriages – Doubly disadvantaged? Part I: Patient perspective. International Journal of Social Psychiatry, 49, 225–232.

30.

Toye

Infanti

(2004). Social inclusion and community economic development: Literature review. Victoria, BC, Canada: The Canadian CED Network.

31.

Ucok

Polat

Cakir

Genc

(2006). One year outcome in first episode schizophrenia. Predictors of relapse. European Archives of Psychiatry and Clinical Neuroscience, 256, 37–43.

32.

Werner

Malaspina

Rabinowitz

(2007). Socioeconomic status at birth is associated with risk of schizophrenia: Population-based multilevel study. Schizophrenia Bulletin, 33, 1373–1378.

33.

World Bank Development Research Group. (2015). GINI index (World Bank estimate). Retrieved from http://data.worldbank.org/indicator/SI.POV.GINI?page=4

34.

World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. WHO, Geneva.

35.

World Health Organization. (2010). Mental Health and Development: Targeting people with mental health conditions as a vulnerable group. Geneva, Switzerland: World Health Organization and Mental Health and Poverty Project.

36.

Xiang

Y. T.

Cai

Z. J.

S. R.

Xiang

Y. Q.

Guo

H. L.

… Ungvari

G. S.

(2008). Prevalence and socio-demographic correlates of schizophrenia in Beijing, China. Schizophrenia Research, 102, 270–277.

37.

Yang

D. T.

(1999). Urban-biased policies and rising income inequality in China. American Economic Review, 89, 306–310.

38.

Yang

L. H.

Chen

Sia

K. J.

Lam

Ngo

… Good

(2014). ‘What matters most’: A cultural mechanism moderating structural vulnerability and moral experience of mental illness stigma. Social Science & Medicine, 103, 84–93.

39.

Yang

L. H.

Kleinman

(2008). ‘Face’ and the embodiment of stigma in China: The cases of schizophrenia and AIDS. Social Science & Medicine, 67, 398–408.

40.

Yang

L. H.

Phillips

M. T.

Zhang

Shi

(2013). Employment outcome for people with schizophrenia in rural v. urban China: Population-based study. British Journal of Psychiatry, 203, 272–279.

41.

Zipursky

R. B.

(2014). Why are the outcomes in patients with schizophrenia so poor? Journal of Clinical Psychiatry, 75(Suppl. 2), 20–24.