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Small head circumference at birth in schizophrenia
192
teristics, and relationship of schizophrenia to pregnancy/birth complications.
STRINGENT CLOZAPINE ELIGIBILITY CRITERIA: IMPACT ON ETHNIC, GENDER, A N D AGAE SUBGROUPS OF SCHIZOPHRENIC PATIENTS Maria Juarez-Reyes*, Martha Shumway, Peter Bacchetti, Cynthia Battle, Mary Susan Hansen, William Hargreaves UCSF/SFGH, 1001 Potrero Ave, Room 7M36, San Francisco,
to diminish in recent decades. These patterns would be expected if stresses associated with cold weather increase risk for schizophrenia, but higher living standards protect against weatherrelated stresses. In the present study, we hypothesized that geographic regions with cold weather would have higher overall schizophrenia prevalence rates, but only for groups of low socioeconomic status. To test this, we compared published data on mean low temperature in different regions with age-corrected schizophrenia prevalence rates for all 50 samples reported in Torrey's (1987) review of all large schizophrenia prevalence studies around the world published over a forty-year period. As hypothesized, greater severity of winter weather was significantly correlated with higher schizophrenia prevalence for economically disadvantaged populations (p < 0.01 ), but not for advantaged ones.
CA 94110, USA
Despite clozapine's effectiveness, use has been restricted because of side effects and costs. Mental health agencies have used more stringent criteria than prescribed by the package insert to control treatment costs. Previously, we estimated clozapine eligibility among schizophrenic patients to be 43% using a broad interpretation of the package insert and 13% using more stringent criteria. This retrospective chart review study determined whether stringent eligibility criteria differentially affected ethnic, gender and age subgroups. Data were collected on 505 schizophrenic patients in an urban mental health agency. With broad criteria, Asian patients were 50% less likely to be eligible than Whites (OR 0.52, p = 0.06). Differential exclusion was observed with 2 stringent criteria. Older patients were more likely to be excluded if automatic eligibility due to TD was eliminated ( O R = 1.99, p < 0.01 ) and less likely to be excluded if more medication trials were required (OR = 0.66, p < 0.01 ). While nonsignificant, odds ratios suggest that Asians (OR=0.36, p=0.06) and Hispanics (OR=0.47, p=0.14) were less likely to be excluded if schizoaffective disorder was not an eligible diagnoses and more likely to be excluded if more medication trials were required (OR = 1.61, p=0.34; OR = 1.61, p=0.33).
TEMPERATURE ASSOCIATED WITH REGIONAL DIFFERENCES IN SCHIZOPHRENIA PREVALENCE RATES Dennis Kinney*, William H y m a n , Aliette Vernooy, Sharon Tramer
Laboratories for Psychiatric Research, NBG-28, McLean Hospital, Belmont, MA 02178, USA Previous analyses of data on over 50 000 schizophrenics in 19 US states found a significant overall excess of schizophrenics born in months with cold weather; across states, moreover, the excess of schizophrenic births in cold months increased significantly as severity of cold weather increased (Kinney et al., 1993). Complementary studies report (a) larger excesses of schizophrenic births in cold months among economically disadvantaged groups, and (b) secular trends for birth-season effects
MATERNAL LONG LABOR A N D SCHIZOHRENIA H. Kunugi*, S. Nanko, N. Takei, K. Saito, R.M. Murray, H. Kazamatsuri Genetics Section, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK There is substantial evidence for an etiological role of obstetric complications (OCs) in schizophrenia. Among OCs, long labor has been considered to be important. However, few studies have reported a significant excess of long labor in schizophrenia. This may be due to the imprecise definition of "long labor" used in psychiatric research. For example, the average labor for the first child (12-15 h) is twice as long as that for the second or later child (5-8 h); however most investigators have not used different cut off points for the first child and the others. We obtained birth records and data on labor for 31 DSM-III-R schizophrenics and 20 healthy controls aged 14-28 in Japan. When labor for the first born schizophrenics (17 h on average, n = 17) was compared with that for the controls (15 h, n = 6) by Mann-Whitney U-tests, there was no significant difference ( Z = - 0 . 7 4 ; p=0.46). However, when comparison was made among the second or later children, labor for the schizophrenics (10h, n = 1 4 ) was significantly longer than that for the controls (6 h, n = 14) ( Z = - 2 . 7 ; p = 0.007). This suggests that schizophrenia is associated with long labor. However, if a particular cut off point, 24 h, for example, was used, we could not find any single individual in the schizophrenics or the controls among second or later born children. The reevaluation of the definition of "long labor" in schizophrenic birth is warranted.
SMALL HEAD CIRCUMFERENCE AT BIRTH IN SCHIZOPHRENIA H. Kunugi*, S. N a n k o , N. Takei, K. Saito, R.M. M u r r a y , H. K a z a m a t s u r i
Genetics Section, Institute of P~ychiatry, De Crespigny Park, London SE5 8AF, UK
193
The recent reformulation of schizophrenia as a neurodevelopment disorder has focused on prenatal development. We compared birthweight and head circumference (HC) at birth between 67 Japanese DSM-III-R schizophrenics (35 males) and the general population (n = 1640). Information on body measures and gestational age at delivery (weeks) was obtained by birth records. When gestational age and gender were controlled for, birthweight in the schizophrenics was not significantly different from average birthweight in the general population (t = -- 0.24; df= 66; p = 0.81 ). However, HC in the schizophrenic neonates was significantly smaller ( t = - 2 . 7 5 ; df=66; p = 0.008). We examined the effects of family history of psychosis (in first or second degree relatives) and season of birth (January`April vs May-December) on the smaller HC. Analyses using ANCOVA, where the effects of gestational age, gender, birth year, and maternal age were adjusted, revealed that individuals with a family history (n = 13) had significantly smaller HC compared with those without a family history (n = 54) (F=9.7; df=l, p=0.003), and that individuals born in January April (n = 19) had significantly smaller HC compared with the others (n=35) among those without a family history (F= 6. l; df= 1; p = 0.015). These results suggest that both family history of psychosis, and birth in winter or early spring are independently associated with the smaller HC possibly resulting from slower brain growth in the preschizophrenic fetus.
RAISED INCIDENCE OF SCHIZOPHRENIA IN UK AFRO-CARIBBEANS--CLUES TO AETIOLOGY J. Left*, D. Bhugra, R. Mallett
Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK Previous studies have found a high incidence of schizophrenia in Afro-Caribbeans in the UK. We have confirmed this finding in an epidemiological study in London comparing the incidence of psychoses in whites, Asians and Afro-Caribbeans. Our rates are likely to be more reliable than previous estimates as we used population figures from the 1991 census, which was the first to include a question on self-ascribed ethnicity. For Schneiderian schizophrenia whites and Asians had similar rates, while Afro-Caribbeans were significantly higher. However, the variation in rates was much greater for non-Schneiderian schizophrenia. Furthermore non-Schneiderian schizophrenia and Afro-Caribbean ethnicity were independently associated with a higher relapse rate during a one year follow-up. A parallel study in Trinidad using identical methods found low rates of Schneiderian and non-Schneiderian schizophrenia. These findings suggest that the high incidence of schizophrenia in UK Afro-Caribbeans is unlikely to be explained genetically. Factors in the social and/or physical environment are likely to be involved. Identification of these could illuminate the aetiology of schizophrenia. The results also suggest that Schneiderian and non-Schneiderian schizophrenia may represent different diagnostic categories.
FACTORS INFLUENCING READMISSIONS OF SCHIZOPHRENICS TO PSYCHIATRIC HOSPITAL R a m m o h a n R a o Malesu
Psychiatric Hospital Black Rock, St. Michael Barbados ( W.L ) The progressive increase in readmissions of patients with schizophrenia in Barbados is a cause of concern. Readmissions of schizophrenics constituted over 70% of the total admissions. In a prospective study of 208 patients of functional psychosis, it was found that male schizophrenics accounted for 62% of the total readmissions. Besides male gender the other demographic characteristics which were strong predictors of readmission were age, unemployment, lower socioeconomic class and homelessness. There was a significant increase of drug abuse, criminal behavior and poor compliance with medication amongst male schizophrenics. Moreover, readmissions occurred overwhelmingly in short-stay patients and patients not included in the community psychiatric services. This study stresses the need for drug rehabilitation for patients with drug abuse, adequate aftercare, rehabilitation facilities in the community, housing facilities including half-way houses to keep readmissions to a minimum.
HANDEDNESS FUNCTIONAL
IN PATIENTS PSYCHOSIS
WITH
R a m m o h a n R a o Malesu*, M. C a n n o n , K.J. McKenzie, K . M . Gilvarry, P. Jones, R.M. M u r r a y
Genetics Section, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK Previous studies on the association between patterns of handedness and mental disorders have yielded varying results. Difference in the choice of handedness questionnaires or inconsistencies in the criteria used to classify handedness could account for the differences. We report a study on the association between patterns of hand preferences and functional psychosis in a large sample of RDC diagnosed patients using the revised Annett's Questionnaire of Hand Preference Classes. The study group consisted of 216 patients (120 with schizophrenia, 41 with schizoaffective disorder and 55 with affective disorder) and 86 normal controls. There was no significant difference between the proportions of right, left and mixed handedness between the patient groups and controls, or within the patient group. No significant correlation was found between handedness and gender, IQ, family history of mental illness, obstetric complications, chronicity or ethnicity. We also found no association of handedness with symptomatology when we examined the 38 Present State Examination (PSE) Clinical Syndromes. We conclude that there is no significant association between anomalous patterns of handedness and functional psychotic illness.
teristics, and relationship of schizophrenia to pregnancy/birth complications.
STRINGENT CLOZAPINE ELIGIBILITY CRITERIA: IMPACT ON ETHNIC, GENDER, A N D AGAE SUBGROUPS OF SCHIZOPHRENIC PATIENTS Maria Juarez-Reyes*, Martha Shumway, Peter Bacchetti, Cynthia Battle, Mary Susan Hansen, William Hargreaves UCSF/SFGH, 1001 Potrero Ave, Room 7M36, San Francisco,
to diminish in recent decades. These patterns would be expected if stresses associated with cold weather increase risk for schizophrenia, but higher living standards protect against weatherrelated stresses. In the present study, we hypothesized that geographic regions with cold weather would have higher overall schizophrenia prevalence rates, but only for groups of low socioeconomic status. To test this, we compared published data on mean low temperature in different regions with age-corrected schizophrenia prevalence rates for all 50 samples reported in Torrey's (1987) review of all large schizophrenia prevalence studies around the world published over a forty-year period. As hypothesized, greater severity of winter weather was significantly correlated with higher schizophrenia prevalence for economically disadvantaged populations (p < 0.01 ), but not for advantaged ones.
CA 94110, USA
Despite clozapine's effectiveness, use has been restricted because of side effects and costs. Mental health agencies have used more stringent criteria than prescribed by the package insert to control treatment costs. Previously, we estimated clozapine eligibility among schizophrenic patients to be 43% using a broad interpretation of the package insert and 13% using more stringent criteria. This retrospective chart review study determined whether stringent eligibility criteria differentially affected ethnic, gender and age subgroups. Data were collected on 505 schizophrenic patients in an urban mental health agency. With broad criteria, Asian patients were 50% less likely to be eligible than Whites (OR 0.52, p = 0.06). Differential exclusion was observed with 2 stringent criteria. Older patients were more likely to be excluded if automatic eligibility due to TD was eliminated ( O R = 1.99, p < 0.01 ) and less likely to be excluded if more medication trials were required (OR = 0.66, p < 0.01 ). While nonsignificant, odds ratios suggest that Asians (OR=0.36, p=0.06) and Hispanics (OR=0.47, p=0.14) were less likely to be excluded if schizoaffective disorder was not an eligible diagnoses and more likely to be excluded if more medication trials were required (OR = 1.61, p=0.34; OR = 1.61, p=0.33).
TEMPERATURE ASSOCIATED WITH REGIONAL DIFFERENCES IN SCHIZOPHRENIA PREVALENCE RATES Dennis Kinney*, William H y m a n , Aliette Vernooy, Sharon Tramer
Laboratories for Psychiatric Research, NBG-28, McLean Hospital, Belmont, MA 02178, USA Previous analyses of data on over 50 000 schizophrenics in 19 US states found a significant overall excess of schizophrenics born in months with cold weather; across states, moreover, the excess of schizophrenic births in cold months increased significantly as severity of cold weather increased (Kinney et al., 1993). Complementary studies report (a) larger excesses of schizophrenic births in cold months among economically disadvantaged groups, and (b) secular trends for birth-season effects
MATERNAL LONG LABOR A N D SCHIZOHRENIA H. Kunugi*, S. Nanko, N. Takei, K. Saito, R.M. Murray, H. Kazamatsuri Genetics Section, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK There is substantial evidence for an etiological role of obstetric complications (OCs) in schizophrenia. Among OCs, long labor has been considered to be important. However, few studies have reported a significant excess of long labor in schizophrenia. This may be due to the imprecise definition of "long labor" used in psychiatric research. For example, the average labor for the first child (12-15 h) is twice as long as that for the second or later child (5-8 h); however most investigators have not used different cut off points for the first child and the others. We obtained birth records and data on labor for 31 DSM-III-R schizophrenics and 20 healthy controls aged 14-28 in Japan. When labor for the first born schizophrenics (17 h on average, n = 17) was compared with that for the controls (15 h, n = 6) by Mann-Whitney U-tests, there was no significant difference ( Z = - 0 . 7 4 ; p=0.46). However, when comparison was made among the second or later children, labor for the schizophrenics (10h, n = 1 4 ) was significantly longer than that for the controls (6 h, n = 14) ( Z = - 2 . 7 ; p = 0.007). This suggests that schizophrenia is associated with long labor. However, if a particular cut off point, 24 h, for example, was used, we could not find any single individual in the schizophrenics or the controls among second or later born children. The reevaluation of the definition of "long labor" in schizophrenic birth is warranted.
SMALL HEAD CIRCUMFERENCE AT BIRTH IN SCHIZOPHRENIA H. Kunugi*, S. N a n k o , N. Takei, K. Saito, R.M. M u r r a y , H. K a z a m a t s u r i
Genetics Section, Institute of P~ychiatry, De Crespigny Park, London SE5 8AF, UK
193
The recent reformulation of schizophrenia as a neurodevelopment disorder has focused on prenatal development. We compared birthweight and head circumference (HC) at birth between 67 Japanese DSM-III-R schizophrenics (35 males) and the general population (n = 1640). Information on body measures and gestational age at delivery (weeks) was obtained by birth records. When gestational age and gender were controlled for, birthweight in the schizophrenics was not significantly different from average birthweight in the general population (t = -- 0.24; df= 66; p = 0.81 ). However, HC in the schizophrenic neonates was significantly smaller ( t = - 2 . 7 5 ; df=66; p = 0.008). We examined the effects of family history of psychosis (in first or second degree relatives) and season of birth (January`April vs May-December) on the smaller HC. Analyses using ANCOVA, where the effects of gestational age, gender, birth year, and maternal age were adjusted, revealed that individuals with a family history (n = 13) had significantly smaller HC compared with those without a family history (n = 54) (F=9.7; df=l, p=0.003), and that individuals born in January April (n = 19) had significantly smaller HC compared with the others (n=35) among those without a family history (F= 6. l; df= 1; p = 0.015). These results suggest that both family history of psychosis, and birth in winter or early spring are independently associated with the smaller HC possibly resulting from slower brain growth in the preschizophrenic fetus.
RAISED INCIDENCE OF SCHIZOPHRENIA IN UK AFRO-CARIBBEANS--CLUES TO AETIOLOGY J. Left*, D. Bhugra, R. Mallett
Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK Previous studies have found a high incidence of schizophrenia in Afro-Caribbeans in the UK. We have confirmed this finding in an epidemiological study in London comparing the incidence of psychoses in whites, Asians and Afro-Caribbeans. Our rates are likely to be more reliable than previous estimates as we used population figures from the 1991 census, which was the first to include a question on self-ascribed ethnicity. For Schneiderian schizophrenia whites and Asians had similar rates, while Afro-Caribbeans were significantly higher. However, the variation in rates was much greater for non-Schneiderian schizophrenia. Furthermore non-Schneiderian schizophrenia and Afro-Caribbean ethnicity were independently associated with a higher relapse rate during a one year follow-up. A parallel study in Trinidad using identical methods found low rates of Schneiderian and non-Schneiderian schizophrenia. These findings suggest that the high incidence of schizophrenia in UK Afro-Caribbeans is unlikely to be explained genetically. Factors in the social and/or physical environment are likely to be involved. Identification of these could illuminate the aetiology of schizophrenia. The results also suggest that Schneiderian and non-Schneiderian schizophrenia may represent different diagnostic categories.
FACTORS INFLUENCING READMISSIONS OF SCHIZOPHRENICS TO PSYCHIATRIC HOSPITAL R a m m o h a n R a o Malesu
Psychiatric Hospital Black Rock, St. Michael Barbados ( W.L ) The progressive increase in readmissions of patients with schizophrenia in Barbados is a cause of concern. Readmissions of schizophrenics constituted over 70% of the total admissions. In a prospective study of 208 patients of functional psychosis, it was found that male schizophrenics accounted for 62% of the total readmissions. Besides male gender the other demographic characteristics which were strong predictors of readmission were age, unemployment, lower socioeconomic class and homelessness. There was a significant increase of drug abuse, criminal behavior and poor compliance with medication amongst male schizophrenics. Moreover, readmissions occurred overwhelmingly in short-stay patients and patients not included in the community psychiatric services. This study stresses the need for drug rehabilitation for patients with drug abuse, adequate aftercare, rehabilitation facilities in the community, housing facilities including half-way houses to keep readmissions to a minimum.
HANDEDNESS FUNCTIONAL
IN PATIENTS PSYCHOSIS
WITH
R a m m o h a n R a o Malesu*, M. C a n n o n , K.J. McKenzie, K . M . Gilvarry, P. Jones, R.M. M u r r a y
Genetics Section, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK Previous studies on the association between patterns of handedness and mental disorders have yielded varying results. Difference in the choice of handedness questionnaires or inconsistencies in the criteria used to classify handedness could account for the differences. We report a study on the association between patterns of hand preferences and functional psychosis in a large sample of RDC diagnosed patients using the revised Annett's Questionnaire of Hand Preference Classes. The study group consisted of 216 patients (120 with schizophrenia, 41 with schizoaffective disorder and 55 with affective disorder) and 86 normal controls. There was no significant difference between the proportions of right, left and mixed handedness between the patient groups and controls, or within the patient group. No significant correlation was found between handedness and gender, IQ, family history of mental illness, obstetric complications, chronicity or ethnicity. We also found no association of handedness with symptomatology when we examined the 38 Present State Examination (PSE) Clinical Syndromes. We conclude that there is no significant association between anomalous patterns of handedness and functional psychotic illness.