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Abstract: Objective: To examine the 17-year clinical outcome of schizophrenia and its predictors in Bali. Methods: Subjects were 59 consecutively admitted first-episode schizophrenia patients. Their clinical outcome was evaluated by standardized symptomatic remission criteria based on Positive and Negative Syndrome Scale (PANSS) scores and operational functional remission criteria at 17-year follow-up. The standardized mortality ratio (SMR) over 17 years was also calculated as another index of clinical outcome. Results: Among these 59 patients, 43 (72.9%) could be followed-up, 15 (25.4%) had died, and one (1.7%) was alive but refused to participate in the study. Combined remission (i.e. symptomatic and functional remission) was achieved in 14 patients (23.7% of original sample). Duration of untreated psychosis (DUP) was a significant baseline predictor of combined remission. Mean age at death of deceased subjects was 35.7, and SMR was 4.85 (95% CI: 2.4–7.3), indicating that deaths were premature. Longer DUP was associated with excess mortality. Conclusions: The long-term outcome of schizophrenia in Bali was heterogeneous, demonstrating that a quarter achieved combined remission, half were in nonremission, and a quarter had died at 17-year follow-up. DUP was a significant predictor both for combined remission and mortality. [Copyright &y& Elsevier]

Aim: The purpose of this naturalistic study was to investigate the rate and predictors of remission at medium-term follow up of individuals with schizophrenia in a community setting in Bali., Methods: Subjects comprised 37 individuals with schizophrenia, including 19 never-treated cases, screened from 8546 general residents. Outcome was evaluated using the standardized symptomatic remission criteria based on Positive and Negative Syndrome Scale scores and operational functional remission criteria at 6-year follow up., Results: Ten individuals (27%) achieved symptomatic remission, 12 (32%) achieved functional remission, and 10 (27%) achieved complete remission (i.e. symptomatic and functional remission). Lower Positive and Negative Syndrome Scale negative symptom score at baseline and receipt of psychiatric treatment for more than half of the follow-up period were predictors of complete remission., Conclusions: The majority of community-screened individuals with schizophrenia failed to achieve complete remission at the 6-year follow up. These results suggest that strategies promoting mental health service utilization among individuals with schizophrenia are essential in Bali., (© 2011 The Authors. Psychiatry and Clinical Neurosciences © 2011 Japanese Society of Psychiatry and Neurology.)

Objective: This community-based study investigated causal beliefs regarding schizophrenia among families of individuals in Bali who screened positive for schizophrenia and examined how their beliefs were related to the individual's psychiatric treatment status., Methods: Causal beliefs of 39 key relatives were examined: 19 of the individuals with schizophrenia had received psychiatric medical treatment and 20 had never received such treatment. A questionnaire developed by the authors that listed 15 possible causes of schizophrenia was used to examine the respondents' beliefs., Results: Key relatives attributed supernatural causes to schizophrenia more often than natural causes. Compared with relatives who listed a natural cause as most important (14 relatives, or 36 percent), relatives who considered a supernatural cause as being the most important (25 relatives, or 64 percent) had a significantly higher mean age and less education and were more likely to have family members with schizophrenia who had never received psychiatric medical treatment., Conclusions: Families' attribution of supernatural causes was strongly related to no receipt of psychiatric medical treatment by the individual with schizophrenia.

The aim of the present study was to trace the help-seeking pathway of mental patients and to elucidate the role of traditional healing in Bali. The source of care before attending Bangli Mental Hospital (Bali) of 54 consecutive patients with no prior psychiatric treatment was investigated. Subjects who had sought help from traditional healers were asked to evaluate treatment effect retrospectively according to a 5-point scale. The pathway to psychiatric care was dominated by traditional healers. Of the patients, 47 (87.0%) consulted a healer (mean number 2.9) before visiting the mental hospital. Consultation with the healers was associated with treatment delay. However, of the 137 traditional healers on the pathway, 11 (8.0%) recommended that the subjects to go to a mental hospital, and all 11 subjects immediately followed the advice. Of the 47 subjects, 14 (29.8%) evaluated the treatment effect as much improved by at least one traditional healer on the pathway, although they ultimately attended the mental hospital. Subjects without psychotic symptoms tended to evaluate the treatment effect as much improved more often than psychotic subjects. Traditional healers function not only as a barrier to reaching psychiatric care, but as either an effective provider of care or a decision-making support for seeking help from psychiatric care for some mental patients in Bali. The knowledge and recognition of psychological disorders by the traditional healers are crucial for early treatment intervention for psychiatric patients.

Background: A considerable number of individuals with schizophrenia go undiagnosed and untreated in developing countries. In the current study, we investigated the prevalence of schizophrenia, the treatment status of individuals with schizophrenia, and factors associated with never-treated status in a Balinese rural community., Method: A door-to-door survey was conducted on 8546 people from the general population to detect individuals with schizophrenia using standardized screening instruments in Bali., Results: Thirty-nine individuals with schizophrenia were identified, giving a point prevalence of 4.2 per 1000 population. Never-treated group subjects (n = 20: 51.3%) had a significantly higher total score on the Positive and Negative Syndrome Scale (p < 0.05) and were less likely to have a history of violent behavior (p < 0.01) than Treated group subjects (n = 19: 48.7%). All 9 subjects who had never shown violent behavior remained untreated., Conclusion: The clinical condition of the never-treated individuals with schizophrenia was poor. Individuals with schizophrenia without violent behavior had no opportunity to undergo medical treatment in this developing country setting.

The present study investigates the differences in public attitudes towards the mentally ill in Bali (Indonesia) and Tokyo (Japan), the former being a non-industrialized society and the latter an industrialized society in Asia. Seventy-seven residents of Bali and 66 residents from Tokyo were examined by a devaluation-discrimination measure and a self-assessment questionnaire to gauge their reactions to five imaginary case study vignettes consisting of three cases of schizophrenia, one case of a depressive episode, and one case of obsessive-compulsive disorder. Balinese respondents had significantly lower devaluation-discrimination measure scores, indicating a more favorable global attitude towards persons with a history of psychiatric treatment than did respondents in Tokyo. However, the extent to which people were prejudicial against mental patients in the two societies varied with the kinds of mental disorders, with Balinese having a more positive attitude to schizophrenics but more negative to depressive and obsessive-compulsive patients.

The present study contrasts the expressed emotion (EE) status in family members of schizophrenic patients between Bali (Indonesia) and Tokyo (Japan), the former being a non-industrialized society and the latter an industrialized society in Asia. The EE ratings of each key relative for 62 consecutively hospitalized schizophrenic patients at the Bangli State Mental Hospital (Bali) and 33 consecutively admitted schizophrenics at Komagino Hospital (Tokyo) were obtained using the Five Minute Speech Sample (FMSS) method. A significantly lower prevalence of high EE (12.9%) was observed in Bali compared with Tokyo (36.4%) (P<0.01). This result may explain the better social adjustment of schizophrenics in Bali. In addition, in Bali, to clarify the EE effect in this non-industrialized society, we examined the relationship between each key relative's EE and the patient's psychotic symptoms at admission, as assessed by the Brief Psychiatric Rating Scale (BPRS) and the Scales for the Assessment of Negative Symptoms (SANS). Moreover, the association between each family member's EE and a patient's rate of re-admission over the 1-year period following discharge was evaluated. The EE value was significantly related to the anxious-depression factor score in the BPRS, but not to either of the other factor scores in the BPRS or SANS subscales. Furthermore, EE status was not a reliable predictor of patient re-admission over the 1-year period following discharge in Bali.

Objective: The aim of the present study was to contrast the outcome of schizophrenic patients between Bali and Tokyo, the former being a non-industrialized society and the latter an industrialized society in Asia., Method: A total of 51 Balinese schizophrenics and 40 schizophrenics in Tokyo were evaluated by five outcome measures at a 5-year follow-up., Results: No significant difference was found in the mean scores of the Positive and Negative Syndrome Scale, Eguma's Social Adjustment Scale and the re-admission rates between the subjects in the two sites. The cumulative length of stay in hospital during the 5-year period was significantly shorter in Bali. The percentage of subjects on psychiatric medication at the follow-up was significantly lower in Bali than that in Tokyo., Conclusion: Although the clinical outcome of schizophrenics in Bali was not superior to that in Tokyo, the subjects in Bali tended to be able to live in society without neuroleptic medication.

We made a comparison of drug treatment for the patients with schizophrenia between two psychiatric hospitals in Tokyo, Japan, and Bali, Indonesia. An initial preliminary, cross-sectional study revealed that the mean daily dose of neuroleptics was significantly higher in Tokyo than it was in Bali. A second, longitudinal, study showed that the mean neuroleptic dose for newly admitted patients in the acute phase was higher, and the number of patients receiving maintenance treatment after discharge larger in Tokyo, while the mean duration of hospitalization was shorter, and the re-admission rate 1 year after discharge lower in Bali. These findings suggest that the course of schizophrenia is more favorable in Bali. As a result of lower dose of neuroleptics, the prevalence of tardic dyskinesia was much lower in Bali than it was in Tokyo.