Illiteracy and schizophrenia in China: a population-based survey

  • Tianli Liu
  • Xinming Song
  • Gong Chen
  • Stephen L. Buka
  • Lei Zhang
  • Lihua Pang
  • Xiaoying ZhengEmail author
Original Paper



Illiterate people may frequently experience social discrimination and exclusion in our modern society. It has been suggested that social adversity increases risk of schizophrenia. The current study examines the relation between illiteracy and schizophrenia.


We utilized data on 1,909,205 representative Chinese people of age 18 years or older collected by the Second China National Sample Survey on Disability in 2006 (participation rate 99.8 %). Experienced clinical psychiatrists diagnosed schizophrenia among those who were psychiatrically disabled with the ICD-10 symptom checklist.


Strikingly high prevalence of schizophrenia was observed among the young illiterates aged 18–29 years (prevalence 1.64 %, 95 % confidence interval (CI) 1.35, 1.93) and 30–39 years (prevalence 1.51 %, 95 % CI 1.34, 1.68), much higher than the prevalence estimates for general Chinese population of similar age reported by any of the previous studies in mainland China. Among people aged less than 40 years, we found that the illiterates were 2.08 times more likely to develop schizophrenia than the literates with no school or primary school education (odds ratio (OR) = 2.08, 95 % CI 1.84, 2.36). The association remained statistically significant after adjustment for age, gender, marital status, household income, and location of residence. Consistently, a strong association between illiteracy and schizophrenia (OR = 2.8, 95 % CI 1.28, 6.11) was found in conditional logistic regression analysis among matched sibling sets aged less than 40 years that further adjusted for genetic confounding.


The risk of schizophrenia may have increased among the socially disadvantaged illiterate people.


Illiteracy Schizophrenia Social cause Social selection Social adversity Social environment 



The work was supported by the National Key Project (973) of Study on Interaction Mechanism of Environment and Genetic of Birth Defect in China (Grant Number 2007CB5119001), State Key Funds of Social Science Project (Research on Disability Prevention Measurement in China, Grant Number 09&ZD072), National Yangzi Scholar Program, 211 and 985 projects of Peking University (Grant Number 20020903), as well as China Postdoctoral Science Foundation (Grant Number 20100480137). The authors gratefully acknowledge Dr. Michael R. Phillips for providing invaluable comments on the manuscript.

Conflict of interest

None disclosed.


  1. 1.
    Jarvis E (1971) Insanity and idiocy in Massachusetts: report of the Commission on Luancy, 1855. Harvard University Press, Cambridge, MAGoogle Scholar
  2. 2.
    Faris REL, Dunham HW (1939) Mental disorders in urban areas: an Ecological Study of Schizophrenia and Other Psychoses. Chicago University Press, ChicagoGoogle Scholar
  3. 3.
    Goldberg EM, Morrison SL (1963) Schizophrenia and social class. Br J Psychiatry 109:785–802PubMedCrossRefGoogle Scholar
  4. 4.
    Woodberry KA, Giuliano AJ, Seidman LJ (2008) Premorbid IQ in schizophrenia: a meta-analytic review. Am J Psychiatry 165(5):579–587. doi: 10.1176/appi.ajp.2008.07081242 PubMedCrossRefGoogle Scholar
  5. 5.
    Swanson CL Jr, Gur RC, Bilker W, Petty RG, Gur RE (1998) Premorbid educational attainment in schizophrenia: association with symptoms, functioning, and neurobehavioral measures. Biol Psychiatry 44(8):739–747 pii: S0006-3223(98)00046-8PubMedCrossRefGoogle Scholar
  6. 6.
    Office of the Second China National Sample Survey on Disability (2007) Documentation of the Second China National Sample Survey on Disability (in Chinese). Statistics Press, BeijingGoogle Scholar
  7. 7.
    Zheng X, Chen G, Song X, Liu J, Yan L, Du W, Pang L, Zhang L, Wu J, Zhang B, Zhang J (2011) Twenty-year trends in the prevalence of disability in China. Bull World Health Organ 89(11):788–797. doi: 10.2471/BLT.11.089730 PubMedCrossRefGoogle Scholar
  8. 8.
    Office of the Second China National Sample Survey on Disability (2006) Working manual for the Second China National Sample Survey on Disability (in Chinese)Google Scholar
  9. 9.
    Office of the Second China National Sample Survey on Disability (2006) Investigator’s manual for the Second China National Sample Survey on Disability (in Chinese)Google Scholar
  10. 10.
    State Population Census Office (2002) Tabulation on the 2000 population census of the People’s Republic of China (in Chinese). China Statistics Press, BeijingGoogle Scholar
  11. 11.
    United Nations (2001) Guidelines and Principles for the Development of Disability Statistics. United Nations Publication, New YorkGoogle Scholar
  12. 12.
    Zhang J (2010) Study of disability survey method Peking University (in Chinese), BeijingGoogle Scholar
  13. 13.
    Office of the Second China National Sample Survey on Disability (2006) Physician’s manual for the Second China National Sample Survey on Disability (in Chinese)Google Scholar
  14. 14.
    WHO (1999) The World Health Organization Disability Assessment Schedule Phase II Field Trial Instrument. The World Health Organization, GenevaGoogle Scholar
  15. 15.
    Ulug B, Ertugrul, A, Go¨gu¨ s, A, Kabakcı, E. (2001) Reliability and validity of the Turkish version of the World Health Organization Disability Assessment Schedule (WHO-DAS-II). Tu¨rk Psikiyatri Dergisi 12:121–130Google Scholar
  16. 16.
    Janca A, Ustun TB, Early TS, Sartorius N (1993) The ICD-10 symptom checklist: a companion to the ICD-10 classification of mental and behavioural disorders. Soc Psychiatry Psychiatr Epidemiol 28(5):239–242PubMedGoogle Scholar
  17. 17.
    St Clair D, Xu M, Wang P, Yu Y, Fang Y, Zhang F, Zheng X, Gu N, Feng G, Sham P, He L (2005) Rates of adult schizophrenia following prenatal exposure to the Chinese famine of 1959–1961. JAMA 294(5):557–562. doi: 10.1001/jama.294.5.557 PubMedCrossRefGoogle Scholar
  18. 18.
    Xiang YT, Ma X, Cai ZJ, Li SR, Xiang YQ, Guo HL, Hou YZ, Li ZB, Li ZJ, Tao YF, Dang WM, Wu XM, Deng J, Lai KY, Ungvari GS (2008) Prevalence and socio-demographic correlates of schizophrenia in Beijing. China Schizophr Res 102(1–3):270–277. doi: 10.1016/j.schres.2008.04.009 CrossRefGoogle Scholar
  19. 19.
    McGuffin P, Owen MJ, Farmer AE (1995) Genetic basis of schizophrenia. Lancet 346(8976):678–682PubMedCrossRefGoogle Scholar
  20. 20.
    Jiang K (2009) Psychiatry (in Chinese), vol 360–2. People’s Medical Publishing House, BeijingGoogle Scholar
  21. 21.
    Jones P, Rodgers B, Murray R, Marmot M (1994) Child development risk factors for adult schizophrenia in the British 1946 birth cohort. Lancet 344(8934):1398–1402PubMedCrossRefGoogle Scholar
  22. 22.
    Murray C, Lopez AD (1996) The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 20. Harvard School of Public Health, CambridgeGoogle Scholar
  23. 23.
    Xi W (2003) A review of the epidemiologic survey reports on schizophrneia (in Chinese). Chinese General Practice 6(8):669–670Google Scholar
  24. 24.
    Phillips MR, Zhang J, Shi Q, Song Z, Ding Z, Pang S, Li X, Zhang Y, Wang Z (2009) Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey. Lancet 373(9680):2041–2053. doi: 10.1016/S0140-6736(09)60660-7 PubMedCrossRefGoogle Scholar
  25. 25.
    Fu L, Ji L, Shen Y, Zhang W, Li S, Chen C, Huang Y, Wang J, Wang D, Tu J, Ning Z, Liu Z, Wu H, Luo K, Zhai S, Yan H, Meng G (1998) Epidemiological survey on mental disability and intellectural impairment in 7 areas of China (in Chinese). Clin J Psychiatry 31(2):81–83Google Scholar
  26. 26.
    Link BG, Phelan J (1995) Social conditions as fundamental causes of disease. J Health Soc Behav Spec No:80–94Google Scholar
  27. 27.
    Tang YL, Gillespie CF, Epstein MP, Mao PX, Jiang F, Chen Q, Cai ZJ, Mitchell PB (2007) Gender differences in 542 Chinese inpatients with schizophrenia. Schizophr Res 97(1–3):88–96. doi: 10.1016/j.schres.2007.05.025 PubMedCrossRefGoogle Scholar
  28. 28.
    National Bureau of Statistics (1991) China Population Statistics Yeabook (in Chinese). China Statistics Press, BeijingGoogle Scholar
  29. 29.
    Fu TM (2005) « Unequal Primary Education Opportunities in Rural and Urban China » , China perpectives [Online], 60 | July–August 2005, Online since 01 June 2008, connection on 24 May 2012. URL:
  30. 30.
    Morgan C, Fisher H (2007) Environment and schizophrenia: environmental factors in schizophrenia: childhood trauma–a critical review. Schizophr Bull 33(1):3–10. doi: 10.1093/schbul/sbl053 PubMedCrossRefGoogle Scholar
  31. 31.
    Selten JP, Cantor-Graae E (2005) Social defeat: risk factor for schizophrenia? Br J Psychiatry 187:101–102. doi: 10.1192/bjp.187.2.101 PubMedCrossRefGoogle Scholar
  32. 32.
    Janssen I, Hanssen M, Bak M, Bijl RV, de Graaf R, Vollebergh W, McKenzie K, van Os J (2003) Discrimination and delusional ideation. Br J Psychiatry 182:71–76PubMedCrossRefGoogle Scholar
  33. 33.
    Cantor-Graae E, Selten JP (2005) Schizophrenia and migration: a meta-analysis and review. Am J Psychiatry 162(1):12–24. doi: 10.1176/appi.ajp.162.1.12 PubMedCrossRefGoogle Scholar
  34. 34.
    Hutchinson G, Haasen C (2004) Migration and schizophrenia: the challenges for European psychiatry and implications for the future. Soc Psychiatry Psychiatr Epidemiol 39(5):350–357. doi: 10.1007/s00127-004-0766-0 PubMedCrossRefGoogle Scholar
  35. 35.
    Boydell J, van Os J, McKenzie K, Allardyce J, Goel R, McCreadie RG, Murray RM (2001) Incidence of schizophrenia in ethnic minorities in London: ecological study into interactions with environment. BMJ 323(7325):1336–1338PubMedCrossRefGoogle Scholar
  36. 36.
    Mallett R, Leff J, Bhugra D, Pang D, Zhao JH (2002) Social environment, ethnicity and schizophrenia. A case–control study. Soc Psychiatry Psychiatr Epidemiol 37(7):329–335. doi: 10.1007/s00127-002-0557-4 PubMedCrossRefGoogle Scholar
  37. 37.
    Corcoran C, Perrin M, Harlap S, Deutsch L, Fennig S, Manor O, Nahon D, Kimhy D, Malaspina D, Susser E (2009) Effect of socioeconomic status and parents’ education at birth on risk of schizophrenia in offspring. Soc Psychiatry Psychiatr Epidemiol 44(4):265–271. doi: 10.1007/s00127-008-0439-5 PubMedCrossRefGoogle Scholar
  38. 38.
    Byrne M, Agerbo E, Eaton WW, Mortensen PB (2004) Parental socio-economic status and risk of first admission with schizophrenia—a Danish national register based study. Soc Psychiatry Psychiatr Epidemiol 39(2):87–96. doi: 10.1007/s00127-004-0715-y PubMedCrossRefGoogle Scholar
  39. 39.
    Werner S, Malaspina D, Rabinowitz J (2007) Socioeconomic status at birth is associated with risk of schizophrenia: population-based multilevel study. Schizophr Bull 33(6):1373–1378. doi: 10.1093/schbul/sbm032 PubMedCrossRefGoogle Scholar
  40. 40.
    Goldberg S, Fruchter E, Davidson M, Reichenberg A, Yoffe R, Weiser M (2011) The relationship between risk of hospitalization for schizophrenia, SES, and cognitive functioning. Schizophr Bull 37(4):664–670. doi: 10.1093/schbul/sbr047 PubMedCrossRefGoogle Scholar
  41. 41.
    Huang Y, Yao G, Dong W (2006) Psychiatric disability standards interpretation (in Chinese). China Disabled People 7:35Google Scholar
  42. 42.
    Murray C, Lopez A (1996) Global health statistics: a conpendium of incidence, prevalence, and mortality estimates for over 200 conditions. Harvard University Press, CambridgeGoogle Scholar
  43. 43.
    Hesketh T, Lu L, Xing ZW (2005) The effect of China’s one-child family policy after 25 years. N Engl J Med 353(11):1171–1176. doi: 10.1056/NEJMhpr051833 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Tianli Liu
    • 1
  • Xinming Song
    • 1
  • Gong Chen
    • 1
  • Stephen L. Buka
    • 2
  • Lei Zhang
    • 1
  • Lihua Pang
    • 1
  • Xiaoying Zheng
    • 1
    Email author
  1. 1.Institute of Population Research/WHO Collaborating Center on Reproductive Health and Population SciencePeking UniversityBeijingPeople’s Republic of China
  2. 2.Department of EpidemiologyBrown UniversityProvidenceUSA

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