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Soc Psychiatry (1987) 22:179-180 Social Psychiatry

9 Springer-Verlag 1987

Life events in schizophrenia

The WHO collaborative study
P. E. Bebbington
MRC Social Psychiatry Unit, Institute of Psychiatry, De Grespigny Park, London, United Kingdom

It has long been accepted that stress has some part schizophrenia must depend upon an integrated
in precipitating episodes of schizophrenia. Life evaluation of several flawed studies. The literature
event studies form part of the basis for this belief, has recently been considerably expanded by the
but their contribution to the evidence has so far ap- publication of a large WHO collaborative study
peared rather fragile to the uncommitted eye. The (Day et al. 1987).
first study by Brown and Birley (1968) used fairly Although limited by the lack of control groups,
sophisticated methods, and suggested that there was the study is important and worth describing in some
an increase in events of various degrees of impact, detail. It was conducted in nine catchment areas
limited to the 3-week period before onset. Jacobs from around the world. Five (Aarhus, Honolulu,
and Myers (1976) also used sophisticated methods, Nagasaki, Prague and Rochester, NY) were in de-
but their inconclusive findings are vitiated by the veloped countries, the remainder (Agra, Chandi-
fact that they chose to examine events in the garh, Cali and Ibadan) in developing countries.
6 month interval before onset, possibly thereby ob- Patients were assessed with the help of the Pre-
scuring, a real increase in frequency limited to the sent State Examination (PSE - Wing et al. 1974).
weeks immediately before onset. This might also The selection of cases was deliberately broad, and
have accounted for the negative results in the study in the final sample an appreciable minority (from
of Malzacher et al. (1981). Al Khani and his col- 6% to 28% in different centres) of cases was given
leagues (1986) used reasonably adequate methods different classifications by the centre psychiatrists
in a Saudi Arabian study, but their results were and the CATEGO program. All told, the study in-
complicated, showing an effect of life events re- cluded 386 cases out of the 435 screened and in
stricted to certain groups. Other studies (Harder et scope. Numbers in individual centres ranged from
al. 1980, Canton and Fraccon 1985) failed to use on- 13 to 84, with the smallest numbers coming from
set to define the end of the period of event collec- Honolulu and Rochester. 'Onset' could be from a
tion, so the events they recorded could have oc- state without symptoms, from one with only minor
curred after onset, thus disqualifying them from neurotic symptoms, or from one with minor psy-
consideration as causal agents. chotic symptoms. Clearly, the last type of onset is in
An ideal study would incorporate standardised reality an exacerbation. Onset from a symptom free
methods of symptomatic assessment and case deft- state occurred in 83% of the cases in Agra and in
nition, limitation to cases where onset was clearly 19% of those from Aarhus. In general, this type of
definable and represented a move from an effective- onset was commoner in the centres in developing
ly symptom free state to a psychotic one, collection countries. Onset in the form of exacerbation charac-
of events in a structured way from a defined period terised from 0% to 19% (Aarhus again) of cases. On-
before onset, careful dating of events so that the sa- set had to occur within six months of screening and
lient period of effect could be identified, unbiased to be capable of being dated to within a one-week
ratings of the impact and independence of events, period. Events were recorded for the three month
and an appropriate control group. No study to date period preceding onset.
meets these requirements, so our conclusions about Life events were elicited using the specially de-
the role of life events in precipitating episodes of veloped WHO Life Events Schedule. This is a semi-

structured interview coveting 70 life event catego- centres with fewest onsets from a symptom free
ties with operationally defined threshold criteria. state appear to be those with the most marked clus-
The interviewers themselves rated the impact of the tering of life events, which raises the possibility of
event on the patient, that is the rating was not made reverse causality, particularly where results are not
blind, 'Independence' ratings were also made after given separately for independent events. On the
the manner of Brown and Harris (1978). Indian cen- face of it, the Indian and Nigerian centres report
tres, and to an extent the Nigerian centre too, used more very acute conditions, and yet many of these
informants as the source of the life event history, do not appear to be related to life events. Clearly,
rather than asking the patients themselves. Events we still lack an adequate explanation for the differ-
were reviewed independently by staff from W H O ences in the course of schizophrenia in the develop-
headquarters. ed and the developing world. The acute benign psy-
In 6 of the 9 centres, event rates per person were choses seen in the latter do not, at any rate from this
very similar, both to each other and to the rates re- study, appear to be psychogenic.
corded in London by Brown and Harris (1978). In Despite these reservations, the study is an im-
the Indian and Nigerian centres, event rates were portant addition to our knowledge, and future anal-
lower. In the Indian centres, this was partly because yses from it must be awaited with interest.
of very low rates of minor events, but rates of mod-
erate and severe events were still somewhat on the
low side. It is not clear which of many possible rea- References
sons could account for this discrepancy, although it
is notable that these centres were the ones that rel- A1 Khani MAF, Bebbington PE, Watson JP, House F (1986) Life
ied wholly or in part on informants for the life event events and schizophrenia: a Saudi Arabian study. Br J Psychi-
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history. Brown GW (1974) Meaning, measurement and stress of life
As it was not possible to establish control events. In: Dohrenwend BS, Dohrenwend BP (eds) Stressful
groups, the value of the findings comes from the life events: their nature and effects. New York, John Wiley,
patterning of life events before onset. Obviously, pp 217-243
Brown GW, Birley JLT (1968) Crises and life changes and the
this could be artefactual, for instance, due to recall onset of schizophrenia. J Health Soc Behav 9:203-214
effects, or the 'search after meaning' (Brown 1974). Brown GW, Harris TO (1978) Social origins of depression. Tavi-
However, these possibilities have not vitiated results stock, London
from studies of life events that have used control Canton G, Fraccon IG (1985) Life events and schizophrenia: a
groups. In all the centres, events tended to cluster replication. Acta Psychiatr Scand 71:211-216
Day R, Neilsen JA, Korten A, Ernberg G, Dube KC, Gebhart J,
in the three weeks before onset, and perhaps, to a Jablensky A, Leon C, Marsella A, Olatawura M, Sartorius N,
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tres when all events were considered together. Num- national study from the World Health Organization. Cult Med
Psychiatry (in press)
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analyse, and the overall event rate in Ibadan was Life events and psychopathology severity among first psychiat-
probably too low to show a significant effect, al- ric admissions. J Abnorm Psychol 89:165-180
though the trend was clear. When independent Jacobs S, Myers J (1976) Recent life events and acute schizo-
events were considered on their own, the results phrenic psychosis: a controlled study. J Nerv Ment Dis 162:
from Nagasaki became nonsignificant (p = 0.1). Ag- Malzacher M, MerzJ, Ebn6ther D (1981) Einschneidende Le-
ra and Chandigarh provided large numbers of pat- bensereignisse im Vorfeld akuter schizophrener Episoden:
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Ideally, the analysis should have included sepa- Press, Cambridge
rate assessment of independent moderate and se-
vere events, although this might require pooling re- EE.Bebbington, MA PhD MRCP MRC Psych
sults from different centres. Nevertheless, the clus- MRC Social Psychiatry Unit
Institut of Psychiatry
tering effects look suggestive. It would also be of De Grespigny Park
value to have analyses for the different types of on- London SE5 8AF
set and for schizophrenia narrowly defined. The United Kingdom