Psychiatric disorders in selected immigrant groups in Camberwell

Review of Major Social Determinants of Health in Schizophrenia-Spectrum Disorders: II. Assessments

BACKGROUND AND AIMS

Social determinants of health (SDoHs) impact the development and course of schizophrenia-spectrum psychotic disorders (SSPDs). Yet, we found no published scholarly reviews of psychometric properties and pragmatic utility of SDoH assessments among people with SSPDs. We aim to review those aspects of SDoH assessments.

STUDY DESIGN

PsychInfo, PubMed, and Google Scholar databases were examined to obtain data on reliability, validity, administration process, strengths, and limitations of the measures for SDoHs identified in a paired scoping review.

STUDY RESULTS

SDoHs were assessed using different approaches including self-reports, interviews, rating scales, and review of public databases. Of the major SDoHs, early-life adversities, social disconnection, racism, social fragmentation, and food insecurity had measures with satisfactory psychometric properties. Internal consistency reliabilities-evaluated in the general population for 13 measures of early-life adversities, social disconnection, racism, social fragmentation, and food insecurity-ranged from poor to excellent (0.68-0.96). The number of items varied from 1 to more than 100 and administration time ranged from less than 5 minutes to over an hour. Measures of urbanicity, low socioeconomic status, immigration status, homelessness/housing instability, and incarceration were based on public records or targeted sampling.

CONCLUSIONS

Although the reported assessments of SDoHs show promise, there is a need to develop and test brief but validated screening measures suitable for clinical application. Novel assessment tools, including objective assessments at individual and community levels utilizing new technology, and sophisticated psychometric evaluations for reliability, validity, and sensitivity to change with effective interventions are recommended, and suggestions for training curricula are offered.

Psychosis, migration and social environment: an age-and-gender controlled study

Purpose

Adverse social experiences are frequently invoked to explain the higher rate of psychosis among migrant groups. The aim of the present study was to establish the socio-environmental factors distinguishing migrant psychotic patients from autochthonous patients.

Subjects and method

We conducted a cross-sectional survey involving 341 migrant psychotic patients matched for age and gender with 341 autochthonous psychotic patients.

Results

Migrant patients lived more often with their parental family, were less often enrolled with a referral psychiatrist, presented a lower rate of employment, a lower percentage of alcohol misuse and of suicide attempts.

Discussion

Our findings add to the growing body of results showing that more attention needs to be focused on socio-environmental variables in psychosis research. However, several limitations have to be taken into account, particularly with regard to selection biases and age of onset of the psychotic illness.

Conclusion

Our results are compatible with the hypothesis that unemployment is a contributing factor in the risk for psychosis among migrant groups. Migrants’ families are an important keystone in the mental health care process of their sick relatives. Our service models need to be adapted with the aim to make the treatment easier for migrant patients.

Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses

PURPOSE

Although excess risks particularly for a diagnosis of schizophrenia have been identified for ethnic minority people in England and other contexts, we sought to identify and synthesise up-to-date evidence (2018) for affective in addition to non-affective psychoses by specific ethnic groups in England.

METHODS

Systematic review and meta-analysis of ethnic differences in diagnosed incidence of psychoses in England, searching nine databases for reviews (citing relevant studies up to 2009) and an updated search in three databases for studies between 2010 and 2018. Studies from both searches were combined in meta-analyses allowing coverage of more specific ethnic groups than previously.

RESULTS

We included 28 primary studies. Relative to the majority population, significantly higher risks of diagnosed schizophrenia were found in Black African (Relative risk, RR 5.72, 95% CI 3.87-8.46, n = 9); Black Caribbean (RR 5.20, 95% CI 4.33-6.24, n = 21); South Asian (RR 2.27, 95% CI 1.63-3.16, n = 14); White Other (RR 2.24, 95% CI 1.59-3.14, n = 9); and Mixed Ethnicity people (RR 2.24, 95% CI 1.32-3.80, n = 4). Significantly higher risks for diagnosed affective psychoses were also revealed: Black African (RR 4.07, 95% CI 2.27-7.28, n = 5); Black Caribbean (RR 2.91, 95% CI 1.78-4.74, n = 16); South Asian (RR 1.71, 95% CI 1.07-2.72, n = 8); White Other (RR 1.55, 95% CI 1.32-1.83, n = 5); Mixed Ethnicity (RR 6.16, 95% CI 3.99-9.52, n = 4).

CONCLUSIONS

The risk for a diagnosis of non-affective and affective psychoses is particularly elevated for Black ethnic groups, but is higher for all ethnic minority groups including those previously not assessed through meta-analyses (White Other, Mixed Ethnicity). This calls for further research on broader disadvantages affecting ethnic minority people.

Schizophrenia and other psychotic disorders in Caribbean-born migrants and their descendants in England: systematic review and meta-analysis of incidence rates, 1950-2013

PURPOSE

Increased risk of schizophrenia and other psychotic disorders among black Caribbean migrants and their descendants have been described since the 1960s. It remains unclear whether this risk varies over time, between rural and urban areas, or according to methodological artefact.

METHODS

We conducted a systematic review of the incidence of adult-onset psychotic disorders in black Caribbean groups relative to the baseline population in England, published 1950-2013. Subject to sufficient data (N ≥ 5) we used random effects meta-analyses to estimate pooled incidence rates (IR) and rate ratios (IRR) of seven psychotic disorder outcomes, and meta-regression to inspect whether any variation was attributable to study-level methodological features, including case ascertainment, denominator reliability, choice of baseline population and study quality.

RESULTS

Eighteen studies met inclusion for review. Sixteen demonstrated statistically significant elevated incidence rates in the black Caribbean group, present across all major psychotic disorders, including schizophrenia and bipolar disorder. Methodological quality increased over time (p = 0.01), but was not associated with estimated IR or IRR. For schizophrenia (N = 11 studies) the pooled IRR in the black Caribbean group was 4.7 (95 % CI 3.9-5.7) relative to the baseline; no evidence of publication bias was observed. We found weak evidence to suggest schizophrenia IRRs were smaller from studies in more urban settings (odds ratio 0.98; 95 % CI 0.96-1.00; p = 0.06).

CONCLUSIONS

Higher incidence rates of psychotic disorders have been present for more than 60 years amongst black Caribbean ethnic groups in England, despite improved study methodologies over time. Aetiological explanations appear to more parsimoniously account for this excess than methodological biases.

Challenges in researching migration status, health and health service use: an intersectional analysis of a South London community

OBJECTIVES

This study aimed to investigate the associations between migration status and health-related outcomes and to examine whether and how the effect of migration status changes when it is disaggregated by length of residence, first language, reason for migration and combined with ethnicity.

DESIGN

A total of 1698 adults were interviewed from 1076 randomly selected households in two South London boroughs. We described the socio-demographic and socio-economic differences between migrants and non-migrants and compared the prevalence of health-related outcomes by migration status, length of residence, first language, reason for migration and migration status within ethnic groups. Unadjusted models and models adjusted for socio-demographic and socio-economic indicators are presented.

RESULTS

Migrants were disadvantaged in terms of socio-economic status but few differences were found between migrant and non-migrants regarding health or health service use indicators; migration status was associated with decreased hazardous alcohol use, functional limitations due to poor mental health and not being registered with a general practitioner. Important differences emerged when migration status was disaggregated by length of residence in the UK, first language, reason for migration and intersected with ethnicity. The association between migration status and functional limitations due to poor mental health was only seen in White migrants, migrants whose first language was not English and migrants who had moved to the UK for work or a better life or for asylum or political reasons. There was no association between migration status and self-rated health overall, but Black African migrants had decreased odds for reporting poor health compared to their non-migrant counterparts [odds ratio = 0.15 (0.05-0.48), p < 0.01].

CONCLUSIONS

Disaggregating migration status by length of residence, first language and reason for migration as well as intersecting it with ethnicity leads to better understanding of the effect migration status has on health and health service use.

Importance of thinking locally for mental health: data from cross-sectional surveys representing South East London and England

BACKGROUND

Reliance on national figures may be underestimating the extent of mental ill health in urban communities. This study demonstrates the necessity for local information on common mental disorder (CMD) and substance use by comparing data from the South East London Community Health (SELCoH) study with those from a national study, the 2007 English Adult Psychiatric Morbidity Study (APMS).

METHODOLOGY/PRINCIPAL FINDINGS

Data were used from two cross-sectional surveys, 1698 men and women residing in south London and 7403 men and women in England. The main outcome, CMD, was indicated by a score of 12 or above on the Revised Clinical Interview Schedule. Secondary outcomes included hazardous alcohol use and illicit drug use. SELCoH sample prevalence estimates of CMD were nearly twice that of the APMS England sample estimates. There was a four-fold greater proportion of depressive episode in the SELCoH sample than the APMS sample. The prevalence of hazardous alcohol use was higher in the national sample. Illicit drug use in the past year was higher in the SELCoH sample, with cannabis and cocaine the illicit drugs reported most frequently in both samples. In comparisons of the SELCoH sample with the APMS England sample and the APMS sample from the Greater London area in combined datasets, these differences remained after adjusting for socio-demographic and socioeconomic indicators for all outcomes.

CONCLUSIONS/SIGNIFICANCE

Local information for estimating the prevalence of CMD and substance use is essential for surveillance and service planning. There were similarities in the demographic and socioeconomic factors related to CMD and substance use across samples.

Incidence of schizophrenia and other psychoses in England, 1950-2009: a systematic review and meta-analyses

BACKGROUND

We conducted a systematic review of incidence rates in England over a sixty-year period to determine the extent to which rates varied along accepted (age, sex) and less-accepted epidemiological gradients (ethnicity, migration and place of birth and upbringing, time).

OBJECTIVES

To determine variation in incidence of several psychotic disorders as above.

DATA SOURCES

Published and grey literature searches (MEDLINE, PSycINFO, EMBASE, CINAHL, ASSIA, HMIC), and identification of unpublished data through bibliographic searches and author communication.

STUDY ELIGIBILITY CRITERIA

Published 1950-2009; conducted wholly or partially in England; original data on incidence of non-organic adult-onset psychosis or one or more factor(s) pertaining to incidence.

PARTICIPANTS

People, 16-64 years, with first -onset psychosis, including non-affective psychoses, schizophrenia, bipolar disorder, psychotic depression and substance-induced psychosis.

STUDY APPRAISAL AND SYNTHESIS METHODS

Title, abstract and full-text review by two independent raters to identify suitable citations. Data were extracted to a standardized extraction form. Descriptive appraisals of variation in rates, including tables and forest plots, and where suitable, random-effects meta-analyses and meta-regressions to test specific hypotheses; rate heterogeneity was assessed by the I²-statistic.

RESULTS

83 citations met inclusion. Pooled incidence of all psychoses (N = 9) was 31.7 per 100,000 person-years (95%CI: 24.6-40.9), 23.2 (95%CI: 18.3-29.5) for non-affective psychoses (N = 8), 15.2 (95%CI: 11.9-19.5) for schizophrenia (N = 15) and 12.4 (95%CI: 9.0-17.1) for affective psychoses (N = 7). This masked rate heterogeneity (I²: 0.54-0.97), possibly explained by socio-environmental factors; our review confirmed (via meta-regression) the typical age-sex interaction in psychosis risk, including secondary peak onset in women after 45 years. Rates of most disorders were elevated in several ethnic minority groups compared with the white (British) population. For example, for schizophrenia: black Caribbean (pooled RR: 5.6; 95%CI: 3.4-9.2; N = 5), black African (pooled RR: 4.7; 95%CI: 3.3-6.8; N = 5) and South Asian groups in England (pooled RR: 2.4; 95%CI: 1.3-4.5; N = 3). We found no evidence to support an overall change in the incidence of psychotic disorder over time, though diagnostic shifts (away from schizophrenia) were reported.

LIMITATIONS

Incidence studies were predominantly cross-sectional, limiting causal inference. Heterogeneity, while evidencing important variation, suggested pooled estimates require interpretation alongside our descriptive systematic results.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Incidence of psychotic disorders varied markedly by age, sex, place and migration status/ethnicity. Stable incidence over time, together with a robust socio-environmental epidemiology, provides a platform for developing prediction models for health service planning.

A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants

BACKGROUND

There is increasing acceptance of migration as a risk factor for schizophrenia and related disorders; however, the magnitude of the risk among second-generation immigrants (SGIs) remains unclear. Generational differences in the incidence of psychotic disorders among migrants might improve our understanding of the relationship between migration, ethnicity and psychotic disorders. This meta-analysis aimed at determining the risk of psychotic disorders among SGIs in comparison with non-migrants and first-generation immigrants (FGIs).

METHOD

Medline, EMBASE and PsycINFO databases were searched systematically for population-based studies on migration and psychotic disorders published between 1977 and 2008. We also contacted experts, tracked citations and screened bibliographies. All potential publications were screened by two independent reviewers in a threefold process. Studies were included in the meta-analysis if they reported incidence data, differentiated FGIs from SGIs and provided age-adjusted data. Data extraction and quality assessment were conducted for each study.

RESULTS

Twenty-one studies met all inclusion criteria. A meta-analysis of 61 effect sizes for FGIs and 28 for SGIs yielded mean-weighted incidence rate ratios (IRRs) of 2.3 [95% confidence interval (CI) 2.0-2.7] for FGIs and 2.1 (95% CI 1.8-2.5) for SGIs. There was no significant risk difference between generations, but there were significant differences according to ethno-racial status and host country.

CONCLUSIONS

The increased risk of schizophrenia and related disorders among immigrants clearly persists into the second generation, suggesting that post-migration factors play a more important role than pre-migration factors or migration per se. The observed variability suggests that the risk is mediated by the social context.

The epidemiology of schizophrenia: replacing dogma with knowledge

Major advances have been made in our understanding of the epidemiology of schizophrenia. We now know that the disorder is more common and severe in young men, and that the incidence varies geographically and temporally. Risk factors have been elucidated; biological risks include a family history of the disorder, advanced paternal age, obstetric complications, and abuse of drugs such as stimulants and cannabis. In addition, recent research has also identified social risk factors such as being born and brought up in a city, migration, and certain types of childhood adversity such as physical abuse and bullying, as well as social isolation and adverse events in adult life. Current research is focussing on the significance of minor psychotic symptoms in the general population, gene-environmental interaction, and how risk factors impact on pathogenesis; perhaps all risk factors ultimately impact on striatal dopamine as the final common pathway.

The culture and identity schedule a measure of cultural affiliation: acculturation, marginalization and schizophrenia

BACKGROUND

Previous epidemiological studies have shown a high incidence of schizophrenia in African-Caribbeans in the UK, but not in Asians.

AIMS

We investigated the hypothesis that cultural adherence might protect the Asians against the stress of living in a majority white culture.

METHODS

The Culture and Identity Schedule (CANDID) was given to patients with a diagnosis of schizophrenia making their first contact with psychiatric services, and to a matched group of controls randomly selected from the general population.

RESULTS

While the Asian patients displayed no drift away from the traditional values as espoused by their controls, the African-Caribbean patients were less traditional than their controls.

CONCLUSIONS

The fact that a movement away from their traditional culture distinguishes African-Caribbean patients with a severe psychiatric illness, schizophrenia, from their mentally healthy controls strongly favours marginalization over biculturalism as an interpretation of this shift.

4. Needs and the deployment of services

An assessment of need for services on the census day, and whether any identified need was being met, was made on the basis of all the information collected from patients, staff, relatives and case-records. Staff judgements that there was unmet need were given considerable weight, since they were usually made when the need was particularly serious or long-lasting. However, in several instances the team rated unmet need as present when staff had not mentioned it. Occasionally, it was necessary to reconcile conflicting information from different sources, as when a relative gave details of problems not known to staff.

3. The role of relatives

Many patients depend on the care and support provided by relatives and friends as much as or more than on the help of services. In order to investigate this role and the burden that it might entail, interviews were sought with those who actually played a practical caring role. Members of the research team asked people in the series and staff whether (a) the patient shared a household with someone, or planned to do so in the near future if living in a residential unit; or (b) the patient regularly visited the relative; or (c) someone regularly helped with tasks such as laundry, washing up or cooking. There were 79 such helpers, all but two of whom turned out to be relatives. One exception was a landlady who had for years provided a very disabled patient with extensive motherly support. The other was a friend who visited the patient every evening in hospital. He used to visit her every day when she was living at home, and helped her round the house when she could not manage. For convenience the term ‘relative’ is used to include these two.

2. Practices of day and residential units in relation to the social behaviour of attenders

There is a considerable variation in the amount and type of care and supervision provided for people in the survey population. At one end of the spectrum, the in-patient ward provides skilled 24-hour medical and nursing care; at the other extreme, some homes are simply providing sheltered housing for ex-patients who would find it very difficult to obtain private rented accommodation in London. Although the sample is defined in terms of service utilization, it covers a broad range of types of treatment, care and social support.

1. Demographic, social and clinical characteristics of the sample

The exploratory survey to be described in this series of papers was designed in order to make a preliminary estimate of the service needs of people in prolonged contact with high dependence community services in Camberwell, including a spell in day or residential care. Patients who had been resident in hospital for a year or more were excluded, but the sampling scheme was otherwise directed towards generating a group who would formerly have been at high risk of staying in hospital for a prolonged period.

Depression and anxiety in labor migrants and refugees--a systematic review and meta-analysis

Prevalence rates of depression and anxiety among migrants (i.e. refugees, labor migrants) vary among studies and it's been found that prevalence rates of depression and anxiety may be linked to financial strain in the country of immigration. Our aim is to review studies on prevalence rates of depression and/or anxiety (acknowledging that Post-traumatic Stress Disorder (PTSD) is within that class of disorders), and to evaluate associations between the Gross National Product (GNP) of the immigration country as a moderating factor for depression, anxiety and PTSD among migrants. We carried out a systematic literature review in the databases MEDLINE and EMBASE for population based studies published from 1990 to 2007 reporting prevalence rates of depression and/or anxiety and or PTSD according to DSM- or ICD- criteria in adults, and a calculation of combined estimates for proportions using the DerSimonian-Laird estimation. A total of 348 records were retrieved with 37 publications on 35 populations meeting our inclusion criteria. 35 studies were included in the final evaluation. Our meta-analysis shows that the combined prevalence rates for depression were 20 percent among labor migrants vs. 44 percent among refugees; for anxiety the combined estimates were 21 percent among labor migrants vs. 40 percent among (n=24,051) refugees. Higher GNP in the country of immigration was related to lower symptom prevalence of depression and/or anxiety in labor migrants but not in refugees. We conclude that depression and/or anxiety in labor migrants and refugees require separate consideration, and that better economic conditions in the host country reflected by a higher GNP appear to be related to better mental health in labor migrants but not in refugees.

Measuring acculturation and symptoms of depression of foreign immigrants in the Athens area

BACKGROUND

Acculturation is the phenomenon that results when a group with one culture comes into continuous contact with a host culture and changes occur in the original culture of either one or both groups. Acculturation has also been linked with stress-related psychological disorder and depression.

AIMS

This article investigates the acculturation process and the depressive state of foreign immigrants living in the greater Athens area.

METHODS

All consecutive cases of 157 foreign immigrants who visited a nongovernmental organization (NGO) providing consultative services to immigrants were interviewed using a structured questionnaire including the Immigrant Acculturation Scale (IAS) and the Centre for Epidemiologic Studies - Depression (CES-D) scale.

RESULTS

Factor analysis of IAS yielded a three-factor solution and 17 items with loadings ranging from 0.74 to 0.41. This scale was also tested and proven to be reliable. The main finding is that the higher the acculturation level of the immigrant individual, the lower the CES-D scale score; the fewer the depressive symptoms are self-reported. Length of stay, existence of family in Greece, legal status of residence and employment were also found to have an effect on depressive symptomatology.

CONCLUSION

Acculturation could be seen as a beneficial mechanism protecting the individual to be exposed to stressful non-adaptive behaviour.

The global prevalence of schizophrenia

Bhugra discusses the implications of a new study in PLoS Medicine that challenges widely held assumptions about the epidemiology of schizophrenia.

A systematic review of the prevalence of schizophrenia

BACKGROUND

Understanding the prevalence of schizophrenia has important implications for both health service planning and risk factor epidemiology. The aims of this review are to systematically identify and collate studies describing the prevalence of schizophrenia, to summarize the findings of these studies, and to explore selected factors that may influence prevalence estimates.

METHODS AND FINDINGS

Studies with original data related to the prevalence of schizophrenia (published 1965-2002) were identified via searching electronic databases, reviewing citations, and writing to authors. These studies were divided into "core" studies, "migrant" studies, and studies based on "other special groups." Between- and within-study filters were applied in order to identify discrete prevalence estimates. Cumulative plots of prevalence estimates were made and the distributions described when the underlying estimates were sorted according to prevalence type (point, period, lifetime, and lifetime morbid risk). Based on combined prevalence estimates, the influence of selected key variables was examined (sex, urbanicity, migrant status, country economic index, and study quality). A total of 1,721 prevalence estimates from 188 studies were identified. These estimates were drawn from 46 countries, and were based on an estimated 154,140 potentially overlapping prevalent cases. We identified 132 core studies, 15 migrant studies, and 41 studies based on other special groups. The median values per 1,000 persons (10%-90% quantiles) for the distributions for point, period, lifetime, and lifetime morbid risk were 4.6 (1.9-10.0), 3.3 (1.3-8.2), 4.0 (1.6-12.1), and 7.2 (3.1-27.1), respectively. Based on combined prevalence estimates, we found no significant difference (a) between males and females, or (b) between urban, rural, and mixed sites. The prevalence of schizophrenia in migrants was higher compared to native-born individuals: the migrant-to-native-born ratio median (10%-90% quantile) was 1.8 (0.9-6.4). When sites were grouped by economic status, prevalence estimates from "least developed" countries were significantly lower than those from both "emerging" and "developed" sites (p = 0.04). Studies that scored higher on a quality score had significantly higher prevalence estimates (p = 0.02).

CONCLUSIONS

There is a wealth of data about the prevalence of schizophrenia. These gradients, and the variability found in prevalence estimate distributions, can provide direction for future hypothesis-driven research.

Incidence of bipolar affective disorder in three UK cities: results from the AESOP study

BACKGROUND

There has been a relative dearth of epidemiological research into bipolar affective disorder. Furthermore, incidence studies of bipolar disorder have been predominantly retrospective and most only included hospital admission cases.

AIMS

To determine the incidence of operationally defined bipolar disorder in three areas of the UK and to investigate any differences in gender and ethnicity.

METHOD

All patients who contacted mental health services with first-episode psychosis or non-psychotic mania between September 1997 and August 1999 were identified and diagnosed according to ICD-10 criteria. Incidence rates of bipolar affective disorder were standardised for age and stratified by gender and ethnic group across the three areas.

RESULTS

The incidence rate per 100,000 per year in south-east London was over twice that in Nottingham and Bristol. There was no significant difference in the rates of disorder in men and women. Incidence rates of bipolar disorder in the combined Black and minority ethnic groups in all three areas were significantly higher than those of the comparison White groups.

CONCLUSIONS

The incidence of bipolar disorder was higher in south-east London than in the other two areas, and was higher among Black and minority ethnic groups than in the White population.

Psychiatric disorders and social characteristics among second-generation Moroccan migrants in Belgium: an age-and gender-controlled study conducted in a psychiatric emergency department

PURPOSE

Clinically, one of the most consistent clinical findings among migrant patients is an increase in the rate of psychosis. The aim of the present study was to confirm this finding in Belgium by comparing second-generation Moroccan migrant patients with Belgian patients, matched for the variables of age and gender.

SUBJECTS AND METHOD

We conducted a cross-sectional survey on 272 patients admitted in a psychiatric emergency unit during the year 1998. We used univariate and multivariate analyses to compare the two subgroups.

RESULTS

Multivariate analyses showed that migrant patients lived more often with their parental family and that they presented a higher rate of admission for psychotic disorders and a lower rate of employment.

DISCUSSION

Our findings add to the growing body of results showing increased incidence of psychosis among immigrants to European countries, but several factors have to be taken into account, particularly with regard to selection biases and differences in help-seeking behaviour and in family perception of the mental illness.

CONCLUSION

Our results are compatible with the hypothesis that unemployment is a contributing factor in the risk for psychosis among migrant groups. Further studies would be needed to better explain some of our results, particularly the role played by the families of migrant patients.

Al Ain community survey of psychiatric morbidity II. Sex differences in the prevalence of depressive disorders

AIM

To examine sex differences in the prevalence of depressive disorders in an Arab community.

METHODS

One thousand three hundred and ninety-four subjects (n=1394) were systematically sampled from the general population in Al-Ain city, United Arab Emirates. All subjects were interviewed and assessed with the modified version of the Composite International Diagnostic Interview (CIDI) and a specially designed socio-demographic questionnaire. The lifetime male and female prevalence rates were estimated. Multivariate logistic regression of various socio-demographic variables was carried out to assess independent risk factors for depression. Statistical significance of sex differences in rates of depression by various socio-demographic groups were also assessed.

RESULTS

The lifetime rates in males and females were 2.8 and 10.3%, respectively. F:M ratio found in this study is highest reported ratio in the literature. Sex, life events, chronic difficulties and to a certain extent age were found to be risk factors for depression in the studied community. The prevalence rates of depression were higher in females in all above categories but such differences reached statistical significance in age category before 55, regardless of marital status, when the number of children is four or more and among those exposed to recent life events and chronic difficulties. Females were found to to be more exposed to chronic life difficulties but only depressed females were significantly more subjected to recent life events.

CONCLUSION

Sex differences in depression is a robust finding but more studies are needed to explain the high F:M ratio found in this survey.

Increased first-contact rates for very-late-onset schizophrenia-like psychosis in African- and Caribbean-born elders

BACKGROUND

Studies have consistently shown a higher incidence of schizophrenia with onset in early adult life in African and Caribbean migrants to the UK.

AIMS

To establish the incidence (first-contact rates) of very-late-onset (>60 years) schizophrenia-like psychosis (SLP) in south London and to test the hypothesis that this is higher among African- and Caribbean-born than indigenous elders.

METHOD

We identified all new referrals of SLP to the Maudsley Hospital between 1995 and 2000. Demographic details, including age, ethnicity and electoral ward (address), were obtained from case notes. Incidence was estimated using 1997 census data to determine the denominator population for each ethnic group.

RESULTS

The incidence of SLP was significantly higher in African- and Caribbean-born than indigenous elders: 172.4 per 100,000 population (95% CI=57.9--286.8) in African- and Caribbean-born males and 323.5 per 100,000 population (95% CI 167.8--479.1) in African- and Caribbean-born females. Rates also were increased in elders from other immigrant groups, but the numbers involved were too small to reach accepted levels of significance.

CONCLUSIONS

Large-scale epidemiological studies are needed to determine both the incidence of and the coexistent risk factors for SLP among all elderly migrants, who may constitute a group with high service needs.

Ethnic disadvantage and schizophrenia

OBJECTIVE

To review and interpret epidemiologic research on ethnic disadvantage and schizophrenia.

METHOD

A search of the research literature was conducted.

RESULTS

Seventeen population-based studies were reported in the United Kingdom and the Netherlands from 1967 to 1997. The studies report high incidence rates for immigrants whose position in society is disadvantaged, than majority-group native-born, with a range of relative incidence from 1.7 to 13.2. It is proposed that the developmental task for formulating the life plan challenges the young adult's executive function abilities, which may be weaker in individuals vulnerable to schizophrenia. Formulating the life plan may be made more difficult by the position in society of disadvantaged ethnic minorities, raising the risk for schizophrenia.

CONCLUSION

Further research on executive function, and the developmental challenge of formulating the life plan, might provide insights into the etiology of schizophrenia, as well as suggest avenues for prevention.

Testing hypotheses on specific environmental causal effects on behavior

There have been strong critiques of the notion that environmental influences can have an important effect on psychological functioning. The substance of these criticisms is considered in order to infer the methodological challenges that have to be met. Concepts of cause and of the testing of causal effects are discussed with a particular focus on the need to consider sample selection and the value (and limitations) of longitudinal data. The designs that may be used to test hypotheses on specific environmental risk mechanisms for psychopathology are discussed in relation to a range of adoption strategies, twin designs, various types of "natural experiments," migration designs, the study of secular change, and intervention designs. In each case, consideration is given to the need for samples that "pull-apart" variables that ordinarily go together, specific hypotheses on possible causal processes, and the specification and testing of key assumptions. It is concluded that environmental risk hypotheses can be (and have been) put to the test but that it is usually necessary to use a combination of research strategies.

Understanding the excess of psychosis among the African-Caribbean population in England. Review of current hypotheses

BACKGROUND

Increased rates of schizophrenia continue to be reported among the African-Caribbean population in England.

AIMS

To evaluate the competing biological, psychological and social explanations that have been proposed.

METHOD

Literature review.

RESULTS

The African-Caribbean population in England is at increased risk of both schizophrenia and mania; the higher rates remain when operational diagnostic criteria are used. The excess of the two psychotic disorders are probably linked: African-Caribbean patients with schizophrenia show more affective symptoms, and a more relapsing course with greater social disruption but fewer chronic negative symptoms, than White patients. No simple hypothesis explains these findings.

CONCLUSIONS

More complex hypotheses are needed. One such links cultural variation in symptom reporting, the use of phenomenological constructs by psychiatrists and social disadvantage.

Early and late environmental risk factors for schizophrenia

Although a high proportion of liability to schizophrenia is under genetic control, a number of environmental risk factors have been identified. The earliest of these are complications of pregnancy and birth, though whether these cause or reflect disturbed brain development is not absolutely clear. Neurodevelopmental deviance is also indicated by neurological dysfunction, social, behavioural and cognitive deficits during childhood. Immigrant status is a significant risk factor, especially prominent among the African Caribbean population in England, though the mechanism is unknown. Later environmental risk factors include adverse life events and substance abuse. An additive model of multiple genetic and environmental risk factors of small effect may be too simplistic and an interactive model where genetic predisposition is compounded by environmental effects is more in keeping with current evidence. The nature of such interactions can be explored more fully when susceptibility genes for schizophrenia are identified.

Ethnic differences in the presentation of bipolar affective disorder

There have been repeated reports that Afro-Caribbean people living in the UK are more prone than white people to be diagnosed as having schizophrenia and mania, along with some evidence that they are less likely to receive a diagnosis of depression. We attempted to replicate these findings in a population of patients on lithium prophylaxis. We therefore assessed the clinical characteristics of people under the age of 55 from three ethnic groups attending a lithium clinic in south London, those of (1) white British (n = 88); (2) Afro-Caribbean (n = 31); and, (3) African (n = 15) origin. Nineteen of the white patients met DSM-IV criteria for unipolar depression (UP) and eight met the criteria for bipolar II disorder (BP II); in contrast, only two black patients met the criteria for unipolar depression and none met the criteria for BP II. Among patients diagnosed as BP I, Africans were significantly more likely than whites to show exclusively or mainly manic presentations while Afro-Caribbeans were more likely to have had mood-incongruent delusions. On the other hand, white patients were significantly more likely than Afro-Caribbeans to have had suicidal ideas or actions, and showed a similar but not significant excess when compared with Africans. Our findings could reflect either genuine ethnic differences in the presentation of severe affective disorder or be produced by the failure of British doctors to detect depression and deliver appropriate treatment to their black patients. The frequency with which Afro-Caribbean patients with mania present mood-incongruent delusions probably contributes to the high rates of diagnosed schizophrenia in this population.

Preliminary study of non-psychotic disorders in people from the Indian subcontinent living in the UK and India

OBJECTIVE

The prevalence of anxiety and depressive disorders in people of South Asian origin in the UK is not accurately known.

METHOD

A population-based study of UK residents from the Indian subcontinent was screened for anxiety and depressive disorders with the Self-Rating Questionnaire (SRQ) and for life events using the brief list of threatening life events. Similar measures were administered to siblings in India.

RESULTS

The UK sample included 223 Sikhs, 100 Hindus and 49 Muslims. Elevated SRQ scores were recorded in 5%, 13% and 23%, respectively, of men from these groups and in 16%, 27% and 57%, respectively, of females. Subjects reporting one or more threatening life events (most commonly unemployment and financial problems) also had raised SRQ scores. A total of 117 siblings in India reported similar SRQ scores to their index subjects in the UK, but reported more threatening life events, notably deaths and illness in the family and financial problems.

CONCLUSION

This preliminary study indicates that psychiatric disorder in ethnic groups varies across religious groups. The prevalence may be high in some religious groups in association with social difficulties. The patterns of stress in India and the UK are different.

Adverse social circumstances and depression in people of Pakistani origin in the UK

BACKGROUND

The social origins of depression in people of Pakistani origin in the UK are not fully understood; they may not be the same as for the indigenous White population.

METHOD

Patients attending a GP's surgery were screened with the Personal Health Questionnaire to detect depressive illness, which was confirmed using the Psychiatric Assessment Schedule; the estimated prevalence of major depression was 42%. Forty-four people with depression and 33 non-depressed comparison subjects were successfully interviewed using the Life Event and Difficulty Schedule, either in Urdu or English.

RESULTS

Seventy-five per cent of the sample were Pakistani born; 57% of cases and 33% of non-cases spoke English with difficulty. Seventy-five per cent of the cases and 36% of the non-cases had experienced an independent severe event and/or a major difficulty (P = 0.0015). Difficulties associated with depression were most commonly in the marital, health and housing categories; overt racial harassment and discrimination were rare.

CONCLUSIONS

This is a preliminary study because of the small sample of GP attenders. The somatic presentation of depression in this population is clear. Acceptable forms of social support and help with marital, housing and employment problems will be needed to help relieve the depression in this population.

Psychiatric disorder in young adults in Jamaica

INTRODUCTION

Much research into psychiatric disorder in Jamaica has investigated psychotic illness but studies of neurotic disorders are lacking. This study investigated psychiatric disorder in a group of mainly urban, lower social class, young adults who had been regular clinic attenders as a physically healthy control group in a cohort study of sickle cell disease.

METHOD

The study was cross-sectional in design. Subjects, 44 male and 45 female, were aged 18 to 20 years at the time of the study. The Psychiatric Assessment Schedule was used to determine psychiatric disorder at Index of Definition level 5.

RESULTS

All subjects approached participated. Rates of psychiatric disorder were 6 (14%) in the male group and 16 (36%) in the female group. There were no psychotic disorders. In the group as a whole, psychiatric disorder was associated with female gender, unemployment, difficulties with social adjustment and number of episodes of physical illness in the 6 months prior to interview. Variables associated with psychiatric distress amongst males included not having a steady relationship, unemployment, criminal activity and difficulties with social adjustment. Variables associated with psychiatric distress amongst females included lack of domestic amenities, not having a mother at home, lack of education, unemployment and social adjustment difficulties.

CONCLUSION

Rates of psychiatric disorder were higher than expected, especially for women. Larger studies are indicated to investigate the prevalence of neurotic disorders amongst young people in Jamaica, compared to similar groups in other countries.

Psychiatry and the popular conception of possession among the Bangladeshis in London

Two detailed case histories of young people possessed by spirits are presented to show that expressions of distress are shaped by cultural beliefs from the very inception. It stands in marked contrast to the Western psychiatric view of possession beliefs as cultural explanations offered for underlying pathological processes. This has serious implications for the practice of psychiatry in increasingly multi cultural societies.

The incidence of mania: time trends in relation to gender and ethnicity

In order to investigate conflicting reports about possible changes in the incidence of mania, we established first contact rates for mania in the defined area of Camberwell between 1965 and 1984. There was some evidence for an increase in the first contact rate of mania, especially in females. This rise may be associated with the influx into Camberwell of individuals of Afro-Caribbean origin who showed significantly higher rates than the white group [adjusted rate ratio 3.1; 95% confidence interval (CI) 1.4-6.9] and more often displayed mixed manic and schizophrenic symptomatology (risk ratio 2.2; 95% CI 1.1-4.3). We conclude that the incidence of mania has not decreased and may actually have increased. High rates of mental illness among members of ethnic minorities are not specific to schizophrenia, suggesting that a risk factor common to both manic and schizophrenic illness is more prevalent among these groups.

Onset study of English-speaking temporary residents in Japan

This is a study of the onset time of psychiatric episodes of 103 English-speaking temporary residents in Japan. The onset time is defined as the interval between the time of arrival in Japan and the request for treatment. The best-fit model was composed of 13 factors and had a highly significant effect on onset time. The existence of a past history of psychiatric disorder was linked with a high vulnerability. Higher proficiency in the language and experience of having been married indicated a lower vulnerability. Vulnerability defined by onset time may share a certain common ground with liability defined by prevalence.

Retroviruses and schizophrenia in Jamaica

Reports of an 18-fold higher incidence of schizophrenia among second-generation Afro-Caribbeans, and especially Jamaican migrants in the United Kingdom were soon called "an epidemic of schizophrenia," with the inference that a novel virus, likely to be perinatally transmitted, was a possible etiological agent. This intriguing observation led us to explore a possible link with human T-cell lymphotropic virus type one (HTLV-I), because it is a virus that is endemic in the Caribbean Island, is perinatally transmitted, known to be neuropathogenic, and the cause of a chronic myelopathy (tropical spastic paraparesis/HTLV-I associated myelopathy. We therefore examined inpatients as the Bellevue Mental Hospital, Kingston, Jamaica and did standard serological tests for retroviruses HTLV-I and HTLV-II and HIV-I and HIV-II on 201 inpatients who fulfilled ICD-9 and DSM III-R criteria for schizophrenia. Our results produced important negative data, since the seropositivity rates for HTLV-I, the most likely pathogen, were no greater than the seropositivity range for HTLV-I carriers in this island population, indicating the HTLV-1 and the other retroviruses tested do not play a primary etiological role in Jamaican schizophrenics.

Psychotic illness in ethnic minorities: clarification from the 1991 census

Age and sex-adjusted first admission rates for operationally-defined schizophrenia and other non-affective psychosis in different ethnic groups were calculated over the period 1988-1992 in a defined catchment area in South London. Standardized rates for schizophrenia, corrected for age- and gender-related under-reporting in the 1991 census and a 20% underestimate of the size of the ethnic minority populations in the area, were not only higher in the Afro-Caribbean group (SMR: 3.1; 95% C1:2.0-4.7), but also in the African group (SMR: 4.2; 95% C1: 2.8-6.2). It was further found that higher rates were not specific to schizophrenia. These findings suggest that some common factor associated with ethnic minority membership is important in producing an excess of psychotic illness.

Psychiatric morbidity among repatriated Greek migrants in a rural area

This paper reports on psychiatric case identification by the application of the Structured Clinical Interview for DSM-III-R (SCID) in a sample of 198 Greek migrants repatriated from western europe in a northwestern province of Greece. The current (1 month) prevalence of psychiatric morbidity, based on the total number of diagnosed cases, was found to be 43.4%. Lifetime prevalence of psychiatric disorders was found to be higher (49.4%). The majority of the sample were diagnosed as suffering from anxiety disorders and dysthymia. Psychiatric disorders were found to be more prevalent among middle-aged respondents. Duration of stay in the foreign country was a factor correlated with psychiatric morbidity. Of short-term migrants 54% were found to suffer from specific nosological entities, whereas 32% of long-term migrants were diagnosed as cases. The results are discussed within the framework of the existing sociocultural context of emigration and repatriation.

Inner london collaborative audit of admission in two health districts. III: Reasons for acute admission to psychiatric wards

BACKGROUND

In this series, rates of admission and daily bed use in south Southwark were 30% higher than in Hammersmith & Fulham, principally because of a higher rate of admission for affective disorders. Factors associated with compulsory admission did not differ between the districts. This final paper examines the severity of symptoms, the reasons given for admission and factors relevant to the judgement to admit, in order to test the hypothesis that more resources mean better service.

METHOD

Sampling and data collection methods were described in the first paper.

RESULTS

In both districts, major reasons for admission were self-neglect and risk of self-harm, poor adaptive functioning, and poor acceptance of medication. In south Southwark, a group of patients had affective disorders and less severe symptoms but a stated risk of suicide. Rates for, and severity of, schizophrenia were similar in the two districts. Social and preventive reasons for admission were given more frequently in south Southwark, where patients had more often been in contact with services before admission. Staff there, but not in Hammersmith & Fulham, suggested that many could have benefited from alternative forms of residential care.

CONCLUSIONS

A 'buffer' of hospital beds in south Southwark may have allowed a more acceptable service, particularly for affective disorders. The possibility that this buffer could be replaced by a wider range of residential accommodation, including hostels away from the District General Hospital, is discussed. Ten recommendations are listed.

Cannabis and acute psychosis

The Present State Examination was used to assess the psychopathology of 23 psychotic patients who were cannabis positive on urinary screening, and 46 matched drug-free controls. Cases and controls were indistinguishable in terms of psychopathology, DSMIII diagnoses, onset of recent illness, the proportion of first admissions, ethnicity, and socio-economic class, differing only in their histories of substance use. These data suggest that psychosis which develops or recurs in the context of cannabis use does not have a characteristic psychopathology or mode of onset, and is not restricted to a particular ethnic or socio-demographic group. There is thus little evidence to support the validity of 'cannabis psychosis' as a diagnostic entity.

Schizophrenia in the Afro-Caribbean community

Previous studies have shown high rates of schizophrenia among the Afro-Caribbean population in Britain. In order to assess the role of genetic factors in the aetiology of this phenomenon, we have used a standardised family history method (FHRDC) to compare lifetime morbidity risks for first-degree relatives of Afro-Caribbean and white patients with RDC schizophrenia admitted in Central Manchester between 1982 and 1988. Lifetime morbidity risk for parents of Afro-Caribbean subjects was 8.9%, and for parents of white patients 8.4%. For the siblings of black probands, however, the risk was 15.9%, as compared with 1.8% for white siblings (P < 0.05). Among siblings of UK-born Afro-Caribbean probands, morbid risk was even higher at 27.3% (P = 0.001). High rates among siblings of younger Afro-Caribbean patients are consistent with previous reports of a higher incidence in the UK-born. These observations suggest that schizophrenia among Afro-Caribbeans is no less familial than for the remainder of the population, but that the increased frequency of the disorder is due to environmental factors which are most common in the Afro-Caribbean community, and capable of precipitating schizophrenia in those who are genetically predisposed.

A follow-up of second generation Afro-Caribbeans and white British with a first admission diagnosis of schizophrenia: attitudes to mental illness and psychiatric services of patients and relatives

A sample of second generation Afro-Caribbeans and white British with a diagnosis of schizophrenia, and their relatives, were interviewed 5-10 years after first admission. There was no difference between Afro-Caribbeans and whites on measures of satisfaction, conceptualization about illness and attitudes to different types of treatment and management. However black relatives were more likely to attribute causation of illness to substance use and to view services as racist. Most black patients and relatives thought that black day centres would be beneficial.

Psychiatric morbidity and compulsory admission among UK-born Europeans, Afro-Caribbeans and Asians in central Manchester

Psychiatric admissions in Central Manchester of Europeans, Afro-Caribbeans, and Asians (within three age-bands) were studied over four years. Among the Afro-Caribbean group there were more single or unemployed persons than in either the Asian or European groups, which suggested greater socio-economic disadvantage. Rates for first admissions and readmissions among Afro-Caribbeans were greater; among Asians they were similar except for the 16-29-year age-group, who tended to have lower rates than Europeans. A higher proportion of Afro-Caribbeans and Asians were psychotic. In the Afro-Caribbean group, the raised rates of admission were largely attributable to increased rates of schizophrenia. The highest rate occurred in second-generation (UK-born) Afro-Caribbeans and was nine times that among Europeans. The police were more frequently involved in the admissions of Afro-Caribbeans compared with Europeans or Asians. Higher proportions of Afro-Caribbeans and Asians who were readmitted were detained under the Mental Health Act 1983, when compared with Europeans.

Depression and anxiety among Afro-Caribbean general practice attenders in Britain

Schizophrenia is diagnosed more frequently among Afro-Caribbeans in Britain than among white British controls. Studies among the general population indicate that non-psychotic disorders such as anxiety, depression and functional somatic symptoms are the commonest expression of psychiatric morbidity. Yet, among Afro-Caribbean primary care attenders, rates of anxiety and depression appear lower than in the general population. This finding is at odds with the reportedly higher rates of schizophrenia among this group. The majority of authors favour socio-cultural explanations to account for the higher rates of schizophrenia. Yet many of the factors that are evoked to account for the greater incidence of schizophrenia would be expected to lead to higher rates of non-psychotic disorders in primary care settings. Possible explanations for these apparently contradictory findings are discussed.

Mental health, race and ethnicity: a retrospective study of the care of ethnic minorities and whites in a psychiatric unit

A retrospective case-note study of 152 discharged psychiatric patients (77 subjects of ethnic minority origin and 75 whites) examined for details of follow-up arrangements on discharge, compliance rate with out-patient appointments and details on length of stay, status on admission, employment status, record of illicit drug taking and diagnosis. The results show that in the areas of diagnosis, possible illicit drug involvement, status on admission and length of stay, there are significant differences between Afro-Caribbean subjects and others.

Schizophrenia and Afro-Caribbeans. A case-control study

A case-control study was performed using 90% of all first-contact patients with a clinical diagnosis of schizophrenia residing in the London borough of Camberwell between 1965 and 1984. Cases and controls were obtained from the Camberwell psychiatric case register. Controls were those presenting with first episodes of non-psychotic disorders, matched for age, sex and period. The risk of schizophrenia was greater in those of Afro-Caribbean ethnicity, irrespective of age, gender or place of birth. This risk increased over the study period. The results cannot be explained by changes in the age, gender or ethnic structure of the local population. Effects of misdiagnosis or change in diagnostic practice were reduced by using uniform operational criteria. Possible explanations include maternal exposure to unfamiliar infective agents, a differential fall in the age at onset of illness, or worsening social adversity.

Day care in an inner city. II. Quality of the services

Seven units providing psychiatric day care to residents of an inner-city area were surveyed. The extent to which the clinical and special problems of attenders were adequately managed by the services was measured using a 'needs-assessment' technique. Units differed in the proportion of clinical and social problems that were rated as 'unmet needs', although the extent of 'unmet need' was not clearly related to the morbidity of attenders at a unit or the available staffing.