Soc Psychiatry (1987) 22:179-180
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
in precipitating episodes of schizophrenia. Life
event studies form part of the basis for this belief,
but their contribution to the evidence has so far ap-
peared rather fragile to the uncommitted eye. The
first study by Brown and Birley (1968) used fairly
sophisticated methods, and suggested that there was
an increase in events of various degrees of impact,
limited to the 3-week period before onset. Jacobs
and Myers (1976) also used sophisticated methods,
but their inconclusive findings are vitiated by the
fact that they chose to examine events in the
6 month interval before onset, possibly thereby ob-
scuring, a real increase in frequency limited to the
weeks immediately before onset. This might also
have accounted for the negative results in the study
of Malzacher et al. (1981). Al Khani and his col-
leagues (1986) used reasonably adequate methods
in a Saudi Arabian study, but their results were
complicated, showing an effect of life events re-
stricted to certain groups. Other studies (Harder et
al. 1980, Canton and Fraccon 1985) failed to use on-
set to define the end of the period of event collec-
tion, so the events they recorded could have oc-
curred after onset, thus disqualifying them from
consideration as causal agents.
An ideal study would incorporate standardised
methods of symptomatic assessment and case deft-
nition, limitation to cases where onset was clearly
definable and represented a move from an effective-
ly symptom free state to a psychotic one, collection
of events in a structured way from a defined period
before onset, careful dating of events so that the sa-
lient period of effect could be identified, unbiased
ratings of the impact and independence of events,
and an appropriate control group. No study to date
meets these requirements, so our conclusions about
the role of life events in precipitating episodes of
Social Psychiatry
schizophrenia must depend upon an integrated
evaluation of several flawed studies. The literature
has recently been considerably expanded by the
publication of a large WHO collaborative study
(Day et al. 1987).
Although limited by the lack of control groups,
the study is important and worth describing in some
detail. It was conducted in nine catchment areas
from around the world. Five (Aarhus, Honolulu,
Nagasaki, Prague and Rochester, NY) were in de-
veloped countries, the remainder (Agra, Chandi-
garh, Cali and Ibadan) in developing countries.
Patients were assessed with the help of the Pre-
sent State Examination (PSE - Wing et al. 1974).
The selection of cases was deliberately broad, and
in the final sample an appreciable minority (from
6% to 28% in different centres) of cases was given
different classifications by the centre psychiatrists
and the CATEGO program. All told, the study in-
cluded 386 cases out of the 435 screened and in
scope. Numbers in individual centres ranged from
13 to 84, with the smallest numbers coming from
Honolulu and Rochester. 'Onset' could be from a
state without symptoms, from one with only minor
neurotic symptoms, or from one with minor psy-
chotic symptoms. Clearly, the last type of onset is in
reality an exacerbation. Onset from a symptom free
state occurred in 83% of the cases in Agra and in
19% of those from Aarhus. In general, this type of
onset was commoner in the centres in developing
countries. Onset in the form of exacerbation charac-
terised from 0% to 19% (Aarhus again) of cases. On-
set had to occur within six months of screening and
to be capable of being dated to within a one-week
period. Events were recorded for the three month
period preceding onset.
Life events were elicited using the specially de-
veloped WHO Life Events Schedule. This is a semi-
180
structured interview coveting 70 life event catego-
ties with operationally defined threshold criteria.
The interviewers themselves rated the impact of the
event on the patient, that is the rating was not made
blind, 'Independence' ratings were also made after
the manner of Brown and Harris (1978). Indian cen-
tres, and to an extent the Nigerian centre too, used
informants as the source of the life event history,
rather than asking the patients themselves. Events
were reviewed independently by staff from W H O
headquarters.
In 6 of the 9 centres, event rates per person were
very similar, both to each other and to the rates re-
corded in London by Brown and Harris (1978). In
the Indian and Nigerian centres, event rates were
lower. In the Indian centres, this was partly because
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-
sons could account for this discrepancy, although it
is notable that these centres were the ones that rel-
ied wholly or in part on informants for the life event
history.
As it was not possible to establish control
groups, the value of the findings comes from the
patterning of life events before onset. Obviously,
this could be artefactual, for instance, due to recall
effects, or the 'search after meaning' (Brown 1974).
However, these possibilities have not vitiated results
from studies of life events that have used control
groups. In all the centres, events tended to cluster
in the three weeks before onset, and perhaps, to a
lesser extent, in the three week period before that.
These results were significant in six of the nine cen-
tres when all events were considered together. Num-
bers in Rochester and Honolulu were too small to
analyse, and the overall event rate in Ibadan was
probably too low to show a significant effect, al-
though the trend was clear. When independent
events were considered on their own, the results
from Nagasaki became nonsignificant (p = 0.1). Ag-
ra and Chandigarh provided large numbers of pat-
ients, and in those centres it was possible to repeat
the analyses for moderate and severe events; a sig-
nificant clustering before onset was again apparent.
Ideally, the analysis should have included sepa-
rate assessment of independent moderate and se-
vere events, although this might require pooling re-
sults from different centres. Nevertheless, the clus-
tering effects look suggestive. It would also be of
value to have analyses for the different types of on-
set and for schizophrenia narrowly defined. The
centres with fewest onsets from a symptom free
state appear to be those with the most marked clus-
tering of life events, which raises the possibility of
reverse causality, particularly where results are not
given separately for independent events. On the
face of it, the Indian and Nigerian centres report
more very acute conditions, and yet many of these
do not appear to be related to life events. Clearly,
we still lack an adequate explanation for the differ-
ences in the course of schizophrenia in the develop-
ed and the developing world. The acute benign psy-
choses seen in the latter do not, at any rate from this
study, appear to be psychogenic.
Despite these reservations, the study is an im-
portant addition to our knowledge, and future anal-
yses from it must be awaited with interest.
References
A1 Khani MAF, Bebbington PE, Watson JP, House F (1986) Life
events and schizophrenia: a Saudi Arabian study. Br J Psychi-
atry 148:12-22
Brown GW (1974) Meaning, measurement and stress of life
events. In: Dohrenwend BS, Dohrenwend BP (eds) Stressful
life events: their nature and effects. New York, John Wiley,
pp 217-243
Brown GW, Birley JLT (1968) Crises and life changes and the
onset of schizophrenia. J Health Soc Behav 9:203-214
Brown GW, Harris TO (1978) Social origins of depression. Tavi-
stock, London
Canton G, Fraccon IG (1985) Life events and schizophrenia: a
replication. Acta Psychiatr Scand 71:211-216
Day R, Neilsen JA, Korten A, Ernberg G, Dube KC, Gebhart J,
Jablensky A, Leon C, Marsella A, Olatawura M, Sartorius N,
Stromgren E, Takahashi R, Wig N, Wynne LC (1987) Stressful
life events preceding the acute onset of schizophrenia: a cross-
national study from the World Health Organization. Cult Med
Psychiatry (in press)
Harder DW, Strauss JS, Kokes RF, Ritzler BA, Gift TE (1980)
Life events and psychopathology severity among first psychiat-
ric admissions. J Abnorm Psychol 89:165-180
Jacobs S, Myers J (1976) Recent life events and acute schizo-
phrenic psychosis: a controlled study. J Nerv Ment Dis 162:
75-87
Malzacher M, MerzJ, Ebn6ther D (1981) Einschneidende Le-
bensereignisse im Vorfeld akuter schizophrener Episoden:
Erstmals erkrankte Patienten im Vergleich mit einer Normal-
stichprobe. Arch Psychiatr Nervenkr 230:227-242
Wing JK, Cooper JE, Sartorius N (1974) The measurement and
classification of psychiatric symptoms. Cambridge University
Press, Cambridge
EE.Bebbington, MA PhD MRCP MRC Psych
MRC Social Psychiatry Unit
Institut of Psychiatry
De Grespigny Park
London SE5 8AF
United Kingdom