- Email: [email protected]
Educational determinants of schizophrenia in the 1966 northern Finland birth cohort study
80
earliest illness manifestation (mode of onset) and may be mediated by negative symptoms. These results emphasise the importance of understanding relationships between aspects of illness onset and initial psychopathology in psychosis. In particular, they suggest that interventions need to be developed to reduce potentially damaging continuities in the early course. Finally, our results suggest that the focus of intervention in first episode psychosis research should extend earlier into development, and broaden its emphasis from positive symptoms.
A. 105. ECOLOGICAL SEGMENTATION ANALYSIS: A N APPROACH TO MODELLING HETEROGENEITY IN EPIDEMIOLOGICAL STUDIES OF AREA DEPRIVATION T.J. Croudace, P.B. Jones
Division of Psychiatry, University of Nottingham, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA, United Kingdom E-mail: Tim. [email protected] The epidemiology of schizophrenia varies with socialeconomic geography and deprivation (Giggs and Cooper, 1987). Similar variation in the treated prevalence of mental disorders provides the rationale for deprivation-based health service funding. We have developed a technology called Ecological Segmentation Analysis which considers the possibility of heterogeneity in deprivation-incidence/prevalence relationships using latent class regression (mixture) models, estimated over ecological units. We illustrate our approach through secondary analysis of a dataset used to derive an index of social deprivation. We identified sub-groups (geographical areas) within the catchment population of electoral wards, in which different relationships between deprivation and annual psychiatric admission prevalence applied. Our latent class regression models characterise this heterogeneity by using semiparametric regression models with varying coefficients. The sub-populations of ecological units in which different relationships hold were then profiled using the Office of National Statistics classification of electoral wards (Wallace et al., 1995). Employing mixture regression models in epidemiological studies of psychosis incidence may identify relationships that elucidate aetiological factors. For mental health services, the technology provides a method for deriving capitation formulae which are tailored to the specific relationships between deprivation and need for services in areas with different profiles of deprivation. ReJerences Giggs J.A., Cooper J.E. (1987) Ecological structure and the distribution of schizophrenia and affective psychoses in Nottingham. British Journal of Psychiatry, 151,627 633. Wallace M., Charlton J., Denham C. (1995) The new OPCS area classifications, Population Trends, 15-30.
A. 106. NONLINEAR RELATIONSHIP BETWEEN A MEASURE OF SOCIAL DEPRIVATION A N D THE INCIDENCE OF PSYCHOSIS IN NOTTINGHAM T.J. Croudace, P.B. Jones, G.L. H a r r i s o n
Division of Psychiatry, University of Nottingham, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA, United Kingdom E-mail: Tim. [email protected]. uk Indicators of population socio-economic disadvantage expressed as weighted 'deprivation indices', e.g. Jarman scores, show strong relationships with measures of psychiatric service activity. We examined the relationship between an index of social deprivation developed specifically to predict psychiatric service activity (the Mental Illness Needs Index; Glover et al., 1998) and the incidence of psychosis (Croudace et al., in press). Ward based incidence rates for ICD-10 psychosis were calculated from a two year first episode study. Relationships with social deprivation were modelled using Poisson regression. Our results highlight an important non-linear relationship between social deprivation and psychosis incidence. Wards with above average deprivation, as measured by MINI, have more new cases of psychoses (and a much higher psychiatric admission prevalence) than would be expected from a simple linear model. These data have implications epidemiological research and resource allocation, by providing information on relative need for services in inner city areas, and suggesting areas where service interventions targetting early psychosis should be located. Further clarification of these patterns is important and may be necessary for more equitable resource allocation and planning of specialist (early intervention) services.
ReJerences Croudace T.J. et al. (1999) Non-linear relationship between an index of social deprivation, psychosis incidence and psychiatric admission prevalence: validation of the Mental Illness Needs Index in Nottingham. Psychological Medicine. In press. Glover G. et al. (1998) A needs index for mental health care, Social Psychiatry and Psychiatric Epidemiology, 33, 89-96.
A. 107. EDUCATIONAL DETERMINANTS OF SCHIZOPHRENIA IN THE 1966 NORTHERN FINLAND BIRTH COHORT STUDY I. Isohanni, P. Jones, M.-R. J~irvelin, J. Jokelainen, P. Rantakallio, M. I s o h a n n i
Polytechnic Oulu, P.O. Box 222, FIN-90101 Oulu, Finland
81
We studied the association between educational performance and later onset schizophrenia experienced by the Northern Finland 1966 Birth Cohort (n= 11,017). School performance was operationalized in two ways: grade level at the age of 14, and mean scores of all school subjects at the age of 16. Educational attainment until the age of 31 was divided into basic, upper secondary and tertiary education. Educational data were linked to data on psychiatric morbidity. By the end of 1994, a total of 87 subjects had schizophrenia. Persons with no psychiatric hospitalization served as a comparison group (n= 10,630). In schizophrenia, not being in the normal school grade was 2.5 times more common than in the comparison group. Mean scores were not lower in schizophrenia. Surprisingly, 11% of pre-schizophrenie boys had excellent mean scores, compared with 3% of the comparison group (OR 3.8; 95% CI 1.6 9.3). Persons with onset at or before age 22 had approximately 4-fold odds for staying in lower educational levels. Late onset cases performed normally. In conclusion, one consequence of schizophrenia is truncated education. We found links between premorbid low and excellent school performance and later schizophrenia, as well as early onset schizophrenia and poor adult educational performance. Our hypothesis of a non-linear association between school performance in adolescence and later schizophrenia may be theoretically relevant to the preservation of schizophrenia in the population, and to mechanisms of developing schizophrenia. Supported by the Theodore and Vada Stanley Foundation.
A. 108. M U L T I P L E A N X I E T Y D I S O R D E R COMORBIDITY IN PATIENTS WITH SCHIZOPHRENIA AND SCHIZOAFFECTIVE DISORDER M. Vilibi6, N. Henigsberg, V. Folnegovi6 Smalc
Department of Psychiato,, Vrap(e Psychiatry Hospital, Bolni6ka c. 32, Zagreb, Croatia Aim: To explore the prevalence of multiple anxiety disorder comorbidity in previously hospitalized, current inpatients with a diagnosis of schizophrenia (SCH) or schizoaffective disorder (SCHAFFD), according to DSM-IV, with particular retrospection to those with preexisted (earlier hospitalizations, periods between hospitalizations) suspicion to coexistence of comorbid anxiety. Method: Subjects were 132, previously hospitalized, current inpatients with exacerbation of psychotic disorder (SCH in 74, SCHAFFD in 58 cases). The diagnosis of SCH and SCHAFF was confirmed and comorbidity was assessed by the Structured Clinical Interview for DSM-III-R (SCID). Questionnaires related to phobias, obsessive-compulsive and general anxiety symptoms were applied, too. Results: The proportion of patients with comorbidity of any anxiety disorder was similar in both groups (37% in SCH; 38% in SCHAFFD group). Social fobia was the most frequent
comorbid anxiety disorder in both groups (the prevalence in SCH group=15%; in S C H A F F D = 17%). The prevalence of generalised anxiety disorder in schizophrenic patients (12%) was higher than that of obsessive-compulsive disorder (10%); while in patients with schizoaffective disorder both prevalences were the same (10%). Conclusions: The prevalence of comorbid anxiety in patients with schizophrenia and schizoaffective disorder was relatively high. Therefore, more complex treatment should result in new psychiatric clinical benefits.
Reference Cosoff, S.J., Hafner R.J. The prevalence of comorbid anxiety in schizophrenia, schizoaffective disorder and bipolar disorder. Aust NZ J Psychiatry 1998 Feb; 32( 1): 67-72.
A . 109. E P I D E M I O L O G Y CHILDHOOD
OF PSYCHOSIS
IN
(EPIC)
D . M . Walker, C. Hollis, K. Cornish, K. Slaveska-Hollis, P. Jones, P. C a w t h r o n
Department of Developmental Psvchiatry, Queen's Medical Centre, E Floor, South Block, Nottingham NG7 2 UH, England Psychotic disorders with onset in childhood and early adolescence are rare, but clinically severe conditions. This study tests the hypothesis that child and adolescent-onset psychoses lie on a continuum with adult onset psychoses. The earlier onset being associated with a higher prevalence of neurodevelopmental and familial risks factors. It also identifies the potential precursors of psychosis in 'high risk' siblings of child/adolescent onset psychotic patients or whether this reportedly higher occurrence (NIMH), is simply a referral artefact. EPIC aims to assess 60 participants aged < 17 at the date of the first contact with mental health services. Participants were recruited via referrals from consultants. All of the participants were assessed on memory, theory of mind, I.Q., and executive functioning. Preliminary data shows that the psychotic participants present with low IQ.; poor theory of mind and impaired memory in comparison to their non-psychotic siblings who are expected to show a superior performance across the tasks but still lower than normals. Siblings are being recruited to account for genetics and environment. Aside from the neuropsychological battery, a series of schedules were given. For example available data suggest that schizophrenic children come from lower socio-economic status (SES) suggesting that the environment has a role in the pathogenesis. Lower SES may also be the result of parental psychopathology with a resultant downward drift in occupational status. Conclusion: EPIC furthers understanding into psychosis in childhood/adolescence. Particularly the impaired neuropsychological components of psychosis which may be integral to the epidemiology of schizophrenia in children and adolescence.
earliest illness manifestation (mode of onset) and may be mediated by negative symptoms. These results emphasise the importance of understanding relationships between aspects of illness onset and initial psychopathology in psychosis. In particular, they suggest that interventions need to be developed to reduce potentially damaging continuities in the early course. Finally, our results suggest that the focus of intervention in first episode psychosis research should extend earlier into development, and broaden its emphasis from positive symptoms.
A. 105. ECOLOGICAL SEGMENTATION ANALYSIS: A N APPROACH TO MODELLING HETEROGENEITY IN EPIDEMIOLOGICAL STUDIES OF AREA DEPRIVATION T.J. Croudace, P.B. Jones
Division of Psychiatry, University of Nottingham, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA, United Kingdom E-mail: Tim. [email protected] The epidemiology of schizophrenia varies with socialeconomic geography and deprivation (Giggs and Cooper, 1987). Similar variation in the treated prevalence of mental disorders provides the rationale for deprivation-based health service funding. We have developed a technology called Ecological Segmentation Analysis which considers the possibility of heterogeneity in deprivation-incidence/prevalence relationships using latent class regression (mixture) models, estimated over ecological units. We illustrate our approach through secondary analysis of a dataset used to derive an index of social deprivation. We identified sub-groups (geographical areas) within the catchment population of electoral wards, in which different relationships between deprivation and annual psychiatric admission prevalence applied. Our latent class regression models characterise this heterogeneity by using semiparametric regression models with varying coefficients. The sub-populations of ecological units in which different relationships hold were then profiled using the Office of National Statistics classification of electoral wards (Wallace et al., 1995). Employing mixture regression models in epidemiological studies of psychosis incidence may identify relationships that elucidate aetiological factors. For mental health services, the technology provides a method for deriving capitation formulae which are tailored to the specific relationships between deprivation and need for services in areas with different profiles of deprivation. ReJerences Giggs J.A., Cooper J.E. (1987) Ecological structure and the distribution of schizophrenia and affective psychoses in Nottingham. British Journal of Psychiatry, 151,627 633. Wallace M., Charlton J., Denham C. (1995) The new OPCS area classifications, Population Trends, 15-30.
A. 106. NONLINEAR RELATIONSHIP BETWEEN A MEASURE OF SOCIAL DEPRIVATION A N D THE INCIDENCE OF PSYCHOSIS IN NOTTINGHAM T.J. Croudace, P.B. Jones, G.L. H a r r i s o n
Division of Psychiatry, University of Nottingham, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA, United Kingdom E-mail: Tim. [email protected]. uk Indicators of population socio-economic disadvantage expressed as weighted 'deprivation indices', e.g. Jarman scores, show strong relationships with measures of psychiatric service activity. We examined the relationship between an index of social deprivation developed specifically to predict psychiatric service activity (the Mental Illness Needs Index; Glover et al., 1998) and the incidence of psychosis (Croudace et al., in press). Ward based incidence rates for ICD-10 psychosis were calculated from a two year first episode study. Relationships with social deprivation were modelled using Poisson regression. Our results highlight an important non-linear relationship between social deprivation and psychosis incidence. Wards with above average deprivation, as measured by MINI, have more new cases of psychoses (and a much higher psychiatric admission prevalence) than would be expected from a simple linear model. These data have implications epidemiological research and resource allocation, by providing information on relative need for services in inner city areas, and suggesting areas where service interventions targetting early psychosis should be located. Further clarification of these patterns is important and may be necessary for more equitable resource allocation and planning of specialist (early intervention) services.
ReJerences Croudace T.J. et al. (1999) Non-linear relationship between an index of social deprivation, psychosis incidence and psychiatric admission prevalence: validation of the Mental Illness Needs Index in Nottingham. Psychological Medicine. In press. Glover G. et al. (1998) A needs index for mental health care, Social Psychiatry and Psychiatric Epidemiology, 33, 89-96.
A. 107. EDUCATIONAL DETERMINANTS OF SCHIZOPHRENIA IN THE 1966 NORTHERN FINLAND BIRTH COHORT STUDY I. Isohanni, P. Jones, M.-R. J~irvelin, J. Jokelainen, P. Rantakallio, M. I s o h a n n i
Polytechnic Oulu, P.O. Box 222, FIN-90101 Oulu, Finland
81
We studied the association between educational performance and later onset schizophrenia experienced by the Northern Finland 1966 Birth Cohort (n= 11,017). School performance was operationalized in two ways: grade level at the age of 14, and mean scores of all school subjects at the age of 16. Educational attainment until the age of 31 was divided into basic, upper secondary and tertiary education. Educational data were linked to data on psychiatric morbidity. By the end of 1994, a total of 87 subjects had schizophrenia. Persons with no psychiatric hospitalization served as a comparison group (n= 10,630). In schizophrenia, not being in the normal school grade was 2.5 times more common than in the comparison group. Mean scores were not lower in schizophrenia. Surprisingly, 11% of pre-schizophrenie boys had excellent mean scores, compared with 3% of the comparison group (OR 3.8; 95% CI 1.6 9.3). Persons with onset at or before age 22 had approximately 4-fold odds for staying in lower educational levels. Late onset cases performed normally. In conclusion, one consequence of schizophrenia is truncated education. We found links between premorbid low and excellent school performance and later schizophrenia, as well as early onset schizophrenia and poor adult educational performance. Our hypothesis of a non-linear association between school performance in adolescence and later schizophrenia may be theoretically relevant to the preservation of schizophrenia in the population, and to mechanisms of developing schizophrenia. Supported by the Theodore and Vada Stanley Foundation.
A. 108. M U L T I P L E A N X I E T Y D I S O R D E R COMORBIDITY IN PATIENTS WITH SCHIZOPHRENIA AND SCHIZOAFFECTIVE DISORDER M. Vilibi6, N. Henigsberg, V. Folnegovi6 Smalc
Department of Psychiato,, Vrap(e Psychiatry Hospital, Bolni6ka c. 32, Zagreb, Croatia Aim: To explore the prevalence of multiple anxiety disorder comorbidity in previously hospitalized, current inpatients with a diagnosis of schizophrenia (SCH) or schizoaffective disorder (SCHAFFD), according to DSM-IV, with particular retrospection to those with preexisted (earlier hospitalizations, periods between hospitalizations) suspicion to coexistence of comorbid anxiety. Method: Subjects were 132, previously hospitalized, current inpatients with exacerbation of psychotic disorder (SCH in 74, SCHAFFD in 58 cases). The diagnosis of SCH and SCHAFF was confirmed and comorbidity was assessed by the Structured Clinical Interview for DSM-III-R (SCID). Questionnaires related to phobias, obsessive-compulsive and general anxiety symptoms were applied, too. Results: The proportion of patients with comorbidity of any anxiety disorder was similar in both groups (37% in SCH; 38% in SCHAFFD group). Social fobia was the most frequent
comorbid anxiety disorder in both groups (the prevalence in SCH group=15%; in S C H A F F D = 17%). The prevalence of generalised anxiety disorder in schizophrenic patients (12%) was higher than that of obsessive-compulsive disorder (10%); while in patients with schizoaffective disorder both prevalences were the same (10%). Conclusions: The prevalence of comorbid anxiety in patients with schizophrenia and schizoaffective disorder was relatively high. Therefore, more complex treatment should result in new psychiatric clinical benefits.
Reference Cosoff, S.J., Hafner R.J. The prevalence of comorbid anxiety in schizophrenia, schizoaffective disorder and bipolar disorder. Aust NZ J Psychiatry 1998 Feb; 32( 1): 67-72.
A . 109. E P I D E M I O L O G Y CHILDHOOD
OF PSYCHOSIS
IN
(EPIC)
D . M . Walker, C. Hollis, K. Cornish, K. Slaveska-Hollis, P. Jones, P. C a w t h r o n
Department of Developmental Psvchiatry, Queen's Medical Centre, E Floor, South Block, Nottingham NG7 2 UH, England Psychotic disorders with onset in childhood and early adolescence are rare, but clinically severe conditions. This study tests the hypothesis that child and adolescent-onset psychoses lie on a continuum with adult onset psychoses. The earlier onset being associated with a higher prevalence of neurodevelopmental and familial risks factors. It also identifies the potential precursors of psychosis in 'high risk' siblings of child/adolescent onset psychotic patients or whether this reportedly higher occurrence (NIMH), is simply a referral artefact. EPIC aims to assess 60 participants aged < 17 at the date of the first contact with mental health services. Participants were recruited via referrals from consultants. All of the participants were assessed on memory, theory of mind, I.Q., and executive functioning. Preliminary data shows that the psychotic participants present with low IQ.; poor theory of mind and impaired memory in comparison to their non-psychotic siblings who are expected to show a superior performance across the tasks but still lower than normals. Siblings are being recruited to account for genetics and environment. Aside from the neuropsychological battery, a series of schedules were given. For example available data suggest that schizophrenic children come from lower socio-economic status (SES) suggesting that the environment has a role in the pathogenesis. Lower SES may also be the result of parental psychopathology with a resultant downward drift in occupational status. Conclusion: EPIC furthers understanding into psychosis in childhood/adolescence. Particularly the impaired neuropsychological components of psychosis which may be integral to the epidemiology of schizophrenia in children and adolescence.