- Email: [email protected]
A comparison of the outcome and treatment of psychosis in UK Afro-Caribbeans and whites
66
degree of urbanization reduced risk. Similarly, risk was modified by changes in residence between ages 5, 10, and 15 years. Conclusion: Frequent moves of address during upbringing increase schizophrenia risk, and urban place of birth and upbringing both contribute to schizophrenia risk. Acknowledgement: The study was supported by the Theodore and Vada Stanley Foundation.
D. Psychosis in Immigrants A.64. SMALL AREA DEPRIVATION AS A CONFOUNDER FOR THE INCREASED INCIDENCE OF PSYCHOSIS IN AFRO-CARIBBEANS J. Brewin, T. Croudace, P. Jones
University of Nottingham, Division of Psychiatry, Duncan Macmillan House, Porchester Road, Mapperley, Nottingham, NG3 6AA, UK An extensive literature exists describing the increased rate of psychosis and schizophrenia in Afro-Caribbean migrants. We have previously reported first contact incidence rates in Nottingham from a prospectively ascertained cohort of 168 patients, assembled from a geographically defined catchment area over a two year period (1992 94). The incidence rate for all psychoses in the Afro-Caribbean population was 174/100,000/year, almost tenfold that of the white population, 18/100,000/year. Using data from the 1991 population census, greater Nottingham was subdivided into zones of social deprivation (population approximately 3000/zone), calculated from 15 indicators of social need, including low income, unemployment, poor housing and health, family and educational difficulties. Using the original cohort incidence rates were recalculated for the white population only in the zones of highest deprivation. These zones correspond to where the majority of the AfroCaribbean population lives. Crude incidence rates (per 100,000 per year), white population only, in areas of high social deprivation in Nottingham n Zone Radford St Anns Sneinton Forest Fields Hyson Green
5 6 4 5 2
All psychoses
Broadly defined schizophrenia (F20 F29)
164 155 115 111 84
131 77 57 44 42
The incidence rates in these small areas are up to 10 times greater than for Nottingham as a whole. In the most deprived areas they are equivalent to the rates in the Afro-Caribbean population. Although the sample size is small, social deprivation has a
significant effect upon the incidence of psychosis, and could explain previous findings of increased rates in Afro-Caribbeans.
A.65. NEIGHBOURHOOD VARIATION IN SCHIZOPHRENIA INCIDENCE: EVIDENCE FOR PERSON-ENVIRONMENT INTERACTION J. van Os, G. Driessen, N. G u n t h e r , Ph. Delespaul
Dept. of Psychiatry and Neuropsychology. Maastrieht University, European Graduate School of Neuroscience, PO Box 616, 6200 MD Maastricht, The Netherlands Background: Neighbourhood characteristics may influence psychosis risk, independent of their individual-level equivalents. Aims: To examine these issues in a multilevel model of schizophrenia incidence. Method: Cases of schizhophrenia, incident between 1986 and 1997, were identified from the Maastricht Mental Health Case Register. A multilevel analysis was conducted to examine the independent effects of individual-level and neighbourhood-level variables in 35 neighbourhoods. Results: Independent of individual-level single and divorced marital status (respectively: RR = 3.95; 95% CI: 2.86, 5.45 and RR=3.31, 95% CI: 2.01, 5.43), an effect of proportion single and proportion divorced in a neighbourhood was apparent (per 1% increase respectively: R R = 1.02; 95% CI: 1.00, 1.03; and RR=I.12, 95% CI: 1.04, 1.21). Single marital status interacted with neighbourhood proportion single, the effect being stronger in neighbourhoods with less single households. Neighbourhood indicators of deprivation had no independent effect after adjustment for age, sex and marital status. Conclusions: The neighbourhood environment modifies individual risk for schizophrenia. Premorbid vulnerability resulting in single marital status may be more likely to progress to overt disease in an environment with higher perceived level of social isolation.
A.66. A COMPARISON OF THE OUTCOME AND TREATMENT OF PSYCHOSIS IN UK AFRO-CARIBBEANS AND WHITES K. McKenzie*, C. Samele, E. van Horn, T. Tartan, J. v a n Os a n d R. M u r r a y for the U K 7 0 0 G r o u p
*Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK The course, outcome and treatment of Afro-Caribbean and British White patients in a large multi-centre sample were compared. 203 Afro-Caribbean and 234 British White patients were selected from a four centre case management trial. Interviews with patients, psychiatric teams, relatives and chart review were used to complete a demographic profile of the patients and the WHO Life Chart 1, DAS z as baseline and two years later.
67
Information on treatment and service use was collected from these and additional sources including computerised records. Groups were compared using regression analyses. Symptoms over the follow-up period, hospitalisation, illness course, self-harm, social disability and treatment were the main outcome variables and socio-economic factors and baseline differences in diagnosis and illness length were possible explanatory variables. Results: British Whites were more likely to have a nonremitting illness course and Afro-Caribbeans were less likely to receive treatment with antidepressants or psychotherapy. Conclusions: Afro-Caribbeans have less poor prognosis illness than British Whites. They are also less likely to receive treatment targetted at affective symptoms regardless of diagnosis.
References 1. WHO Psychiatric Disability Assessment Schedule, 1988, Geneva, WHO. 2. WHO Schedules for assessment in neuropsychiatry, 1992, Geneva, WHO.
A.67. LOWER PREVALENCE OF PREMORBID NEUROLOGICAL ILLNESS UK AFRO-CARIBBEAN THAN WHITE PSYCHOTICS
IN
K. McKenzie*, P. Jones, S. Lewis, I. Harvey, B. Toone, P. Sham, R.M. M u r r a y
*Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK The increased incidence of psychosis in U K Afro-Caribbeans may be due to illnesses with a social aetiology 1. If this is the case, the prevalence of neurodevelopmental risk factors such as obstetric complications and premorbid neurological illness would be lower in Afro-Caribbean than White psychotic patients. Method: Details of obstetric complications and premorbid neurological illness were obtained by maternal and patient interview and chart review concerning 103 Afro-Caribbeans and 337 Whites with psychosis drawn from 2 consecutive admission series2'3. A regression analysis, including age, sex, social class and diagnosis as explanatory variables, was used to compare the proportion of patients with each 'risk factor'. Results: Premorbid neurological disorders were less common in Afro-Caribbeans than Whites (odds ratio 0.19, 95% CI. 0.06 0.61). Afro-Caribbeans reported fewer obstetric complications (21.5%) than Whites (30.9%) but this difference was not statistically significant. Conclusion: There are differences in the risk factor profiles for psychosis between UK Afro-Caribbeans and White psychotics.
References 1. McKenzie K., van Os J., Fahy T., et al. (1995). Psychosis of good prognosis in Afro-Caribbean people now living in the UK. BMJ 311: 1135-1328. 2. Harvey I., Williams M., McGuffin P., et al. (1990). The
functional psychoses in Afro-Caribbeans. BJPsych 157: 515-522. 3. Jones P.B., Bebbington P, Forester A., et al. (1993). Premorbid social underachievement in schizophrenia, results of the Camberwell Collaborative Study. BJPsych 162: 65-71.
A.68. INCREASED RATES OF PSYCHOSIS AMONG IMMIGRANTS IN MALMO E. C a n t o r - G r a a e , K. Zolkowska, T.F. McNeil
Department of Community Medicine, Lund University, University Hospital Maim6, Sweden S-205 02 Findings of increased incidence of schizophrenia and schizophrenia-like psychoses among selected immigrant groups in the UK and The Netherlands are still lacking a satisfactory explanation. Malm6, Sweden's third largest city, is well suited for a study of the relationship between psychosis and migration due to the concentration of immigrants residing in the city (28% of the population) and access to reliable demographic information. All patients admitted to any adult in-patient psychiatric treatment facility in Malm6 during a 12-month period (970,401-980,331) were studied with regard to ethnic background, DSM-IV discharge diagnosis, and the clinical and demographic information available from the case records. Ageand sex-standardized admission rates for schizophrenia and schizophrenia-like psychoses were significantly elevated among immigrants. Admission rates were specifically increased among immigrants from Eastern Europe and Africa (Somalia-Eritrea). Immigrants with psychosis more often had family history of psychosis and previous contact with psychiatry prior to migration than immigrant patients with non-psychotic disorders. A one-year incidence study (1998) of all newly debuting psychosis cases (both hospitalized and not yet hospitalized patients) in Malm6 also yielded significantly elevated rates of psychosis among immigrants.
E. Perinatal Complications and Other Risk Factors A.69. MATERNAL PRENATAL INFECTIONS AND ADULT PSYCHOSIS: A FORTY YEAR PROSPECTIVE STUDY S.L. Buka, M.T. Tsuang, E.F. Torrey, M.A. Klebanof, D. Bernstein, R.H. Yolken
Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA Background: Previous studies have suggested that maternal exposure to infections is a risk factor for the development of schizophrenia in adult life. Methods: We identified adults with schizophrenia and other psychotic illnesses whose mothers had been enrolled in the
degree of urbanization reduced risk. Similarly, risk was modified by changes in residence between ages 5, 10, and 15 years. Conclusion: Frequent moves of address during upbringing increase schizophrenia risk, and urban place of birth and upbringing both contribute to schizophrenia risk. Acknowledgement: The study was supported by the Theodore and Vada Stanley Foundation.
D. Psychosis in Immigrants A.64. SMALL AREA DEPRIVATION AS A CONFOUNDER FOR THE INCREASED INCIDENCE OF PSYCHOSIS IN AFRO-CARIBBEANS J. Brewin, T. Croudace, P. Jones
University of Nottingham, Division of Psychiatry, Duncan Macmillan House, Porchester Road, Mapperley, Nottingham, NG3 6AA, UK An extensive literature exists describing the increased rate of psychosis and schizophrenia in Afro-Caribbean migrants. We have previously reported first contact incidence rates in Nottingham from a prospectively ascertained cohort of 168 patients, assembled from a geographically defined catchment area over a two year period (1992 94). The incidence rate for all psychoses in the Afro-Caribbean population was 174/100,000/year, almost tenfold that of the white population, 18/100,000/year. Using data from the 1991 population census, greater Nottingham was subdivided into zones of social deprivation (population approximately 3000/zone), calculated from 15 indicators of social need, including low income, unemployment, poor housing and health, family and educational difficulties. Using the original cohort incidence rates were recalculated for the white population only in the zones of highest deprivation. These zones correspond to where the majority of the AfroCaribbean population lives. Crude incidence rates (per 100,000 per year), white population only, in areas of high social deprivation in Nottingham n Zone Radford St Anns Sneinton Forest Fields Hyson Green
5 6 4 5 2
All psychoses
Broadly defined schizophrenia (F20 F29)
164 155 115 111 84
131 77 57 44 42
The incidence rates in these small areas are up to 10 times greater than for Nottingham as a whole. In the most deprived areas they are equivalent to the rates in the Afro-Caribbean population. Although the sample size is small, social deprivation has a
significant effect upon the incidence of psychosis, and could explain previous findings of increased rates in Afro-Caribbeans.
A.65. NEIGHBOURHOOD VARIATION IN SCHIZOPHRENIA INCIDENCE: EVIDENCE FOR PERSON-ENVIRONMENT INTERACTION J. van Os, G. Driessen, N. G u n t h e r , Ph. Delespaul
Dept. of Psychiatry and Neuropsychology. Maastrieht University, European Graduate School of Neuroscience, PO Box 616, 6200 MD Maastricht, The Netherlands Background: Neighbourhood characteristics may influence psychosis risk, independent of their individual-level equivalents. Aims: To examine these issues in a multilevel model of schizophrenia incidence. Method: Cases of schizhophrenia, incident between 1986 and 1997, were identified from the Maastricht Mental Health Case Register. A multilevel analysis was conducted to examine the independent effects of individual-level and neighbourhood-level variables in 35 neighbourhoods. Results: Independent of individual-level single and divorced marital status (respectively: RR = 3.95; 95% CI: 2.86, 5.45 and RR=3.31, 95% CI: 2.01, 5.43), an effect of proportion single and proportion divorced in a neighbourhood was apparent (per 1% increase respectively: R R = 1.02; 95% CI: 1.00, 1.03; and RR=I.12, 95% CI: 1.04, 1.21). Single marital status interacted with neighbourhood proportion single, the effect being stronger in neighbourhoods with less single households. Neighbourhood indicators of deprivation had no independent effect after adjustment for age, sex and marital status. Conclusions: The neighbourhood environment modifies individual risk for schizophrenia. Premorbid vulnerability resulting in single marital status may be more likely to progress to overt disease in an environment with higher perceived level of social isolation.
A.66. A COMPARISON OF THE OUTCOME AND TREATMENT OF PSYCHOSIS IN UK AFRO-CARIBBEANS AND WHITES K. McKenzie*, C. Samele, E. van Horn, T. Tartan, J. v a n Os a n d R. M u r r a y for the U K 7 0 0 G r o u p
*Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK The course, outcome and treatment of Afro-Caribbean and British White patients in a large multi-centre sample were compared. 203 Afro-Caribbean and 234 British White patients were selected from a four centre case management trial. Interviews with patients, psychiatric teams, relatives and chart review were used to complete a demographic profile of the patients and the WHO Life Chart 1, DAS z as baseline and two years later.
67
Information on treatment and service use was collected from these and additional sources including computerised records. Groups were compared using regression analyses. Symptoms over the follow-up period, hospitalisation, illness course, self-harm, social disability and treatment were the main outcome variables and socio-economic factors and baseline differences in diagnosis and illness length were possible explanatory variables. Results: British Whites were more likely to have a nonremitting illness course and Afro-Caribbeans were less likely to receive treatment with antidepressants or psychotherapy. Conclusions: Afro-Caribbeans have less poor prognosis illness than British Whites. They are also less likely to receive treatment targetted at affective symptoms regardless of diagnosis.
References 1. WHO Psychiatric Disability Assessment Schedule, 1988, Geneva, WHO. 2. WHO Schedules for assessment in neuropsychiatry, 1992, Geneva, WHO.
A.67. LOWER PREVALENCE OF PREMORBID NEUROLOGICAL ILLNESS UK AFRO-CARIBBEAN THAN WHITE PSYCHOTICS
IN
K. McKenzie*, P. Jones, S. Lewis, I. Harvey, B. Toone, P. Sham, R.M. M u r r a y
*Department of Psychological Medicine, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK The increased incidence of psychosis in U K Afro-Caribbeans may be due to illnesses with a social aetiology 1. If this is the case, the prevalence of neurodevelopmental risk factors such as obstetric complications and premorbid neurological illness would be lower in Afro-Caribbean than White psychotic patients. Method: Details of obstetric complications and premorbid neurological illness were obtained by maternal and patient interview and chart review concerning 103 Afro-Caribbeans and 337 Whites with psychosis drawn from 2 consecutive admission series2'3. A regression analysis, including age, sex, social class and diagnosis as explanatory variables, was used to compare the proportion of patients with each 'risk factor'. Results: Premorbid neurological disorders were less common in Afro-Caribbeans than Whites (odds ratio 0.19, 95% CI. 0.06 0.61). Afro-Caribbeans reported fewer obstetric complications (21.5%) than Whites (30.9%) but this difference was not statistically significant. Conclusion: There are differences in the risk factor profiles for psychosis between UK Afro-Caribbeans and White psychotics.
References 1. McKenzie K., van Os J., Fahy T., et al. (1995). Psychosis of good prognosis in Afro-Caribbean people now living in the UK. BMJ 311: 1135-1328. 2. Harvey I., Williams M., McGuffin P., et al. (1990). The
functional psychoses in Afro-Caribbeans. BJPsych 157: 515-522. 3. Jones P.B., Bebbington P, Forester A., et al. (1993). Premorbid social underachievement in schizophrenia, results of the Camberwell Collaborative Study. BJPsych 162: 65-71.
A.68. INCREASED RATES OF PSYCHOSIS AMONG IMMIGRANTS IN MALMO E. C a n t o r - G r a a e , K. Zolkowska, T.F. McNeil
Department of Community Medicine, Lund University, University Hospital Maim6, Sweden S-205 02 Findings of increased incidence of schizophrenia and schizophrenia-like psychoses among selected immigrant groups in the UK and The Netherlands are still lacking a satisfactory explanation. Malm6, Sweden's third largest city, is well suited for a study of the relationship between psychosis and migration due to the concentration of immigrants residing in the city (28% of the population) and access to reliable demographic information. All patients admitted to any adult in-patient psychiatric treatment facility in Malm6 during a 12-month period (970,401-980,331) were studied with regard to ethnic background, DSM-IV discharge diagnosis, and the clinical and demographic information available from the case records. Ageand sex-standardized admission rates for schizophrenia and schizophrenia-like psychoses were significantly elevated among immigrants. Admission rates were specifically increased among immigrants from Eastern Europe and Africa (Somalia-Eritrea). Immigrants with psychosis more often had family history of psychosis and previous contact with psychiatry prior to migration than immigrant patients with non-psychotic disorders. A one-year incidence study (1998) of all newly debuting psychosis cases (both hospitalized and not yet hospitalized patients) in Malm6 also yielded significantly elevated rates of psychosis among immigrants.
E. Perinatal Complications and Other Risk Factors A.69. MATERNAL PRENATAL INFECTIONS AND ADULT PSYCHOSIS: A FORTY YEAR PROSPECTIVE STUDY S.L. Buka, M.T. Tsuang, E.F. Torrey, M.A. Klebanof, D. Bernstein, R.H. Yolken
Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA Background: Previous studies have suggested that maternal exposure to infections is a risk factor for the development of schizophrenia in adult life. Methods: We identified adults with schizophrenia and other psychotic illnesses whose mothers had been enrolled in the