Symptoms at first contact for psychotic disorder: comparison between native Dutch and ethnic minorities

Psychosis superspectrum I: Nosology, etiology, and lifespan development

This review describes the Hierarchical Taxonomy of Psychopathology (HiTOP) model of psychosis-related psychopathology, the psychosis superspectrum. The HiTOP psychosis superspectrum was developed to address shortcomings of traditional diagnoses for psychotic disorders and related conditions including low reliability, arbitrary boundaries between psychopathology and normality, high symptom co-occurrence, and heterogeneity within diagnostic categories. The psychosis superspectrum is a transdiagnostic dimensional model comprising two spectra-psychoticism and detachment-which are in turn broken down into fourteen narrow components, and two auxiliary domains-cognition and functional impairment. The structure of the spectra and their components are shown to parallel the genetic structure of psychosis and related traits. Psychoticism and detachment have distinct patterns of association with urbanicity, migrant and ethnic minority status, childhood adversity, and cannabis use. The superspectrum also provides a useful model for describing the emergence and course of psychosis, as components of the superspectrum are relatively stable over time. Changes in psychoticism predict the onset of psychosis-related psychopathology, whereas changes in detachment and cognition define later course. Implications of the superspectrum for genetic, socio-environmental, and longitudinal research are discussed. A companion review focuses on neurobiology, treatment response, and clinical utility of the superspectrum, and future research directions.

Differences in clinical presentation at first hospitalization and the impact on involuntary admissions among first-generation migrant groups with non-affective psychotic disorders

BACKGROUND

Some migrant and ethnic minority groups have a higher risk of coercive pathways to care; however, it is unclear whether differences in clinical presentation contribute to this risk. We sought to assess: (i) whether there were differences in clinician-rated symptoms and behaviours across first-generation immigrant and refugee groups at the first psychiatric hospitalization after psychosis diagnosis, and (ii) whether these differences accounted for disparities in involuntary admission.

METHODS

Using population-based health administrative data from Ontario, Canada, we constructed a sample (2009-2013) of incident cases of non-affective psychotic disorder followed for two years to identify first psychiatric hospitalization. We compared clinician-rated symptoms and behaviours at admission between first-generation immigrants and refugees and the general population, and adjusted for these variables to ascertain whether the elevated prevalence of involuntary admission persisted.

RESULTS

Immigrants and refugee groups tended to have lower ratings for affective symptoms, self-harm behaviours, and substance use, as well as higher levels of medication nonadherence and poor insight. Immigrant groups were more likely to be perceived as aggressive and a risk of harm to others, and both groups were perceived as having self-care issues. Adjustment for perceived differences in clinical presentation at admission did not attenuate the higher prevalence of involuntary admission for immigrant and refugee groups.

CONCLUSIONS

First-generation migrant groups may differ in clinical presentation during the early course of psychotic illness, although these perceived differences did not explain the elevated rates of involuntary admission. Further research using outpatient samples and tools with established cross-cultural validity are warranted.

Depression among Turkish and Moroccan immigrant populations in Northwestern Europe: a systematic review of prevalence and correlates

BACKGROUND

This systematic review aimed to synthesize the prevalence and correlates of depressive disorders and symptoms of Turkish and Moroccan immigrant populations in Northwestern Europe, formulating evidence-informed recommendations for clinical practice.

METHODS

We conducted a systematic search in PsycINFO, MEDLINE, Science Direct, Web of Knowledge, and Cochrane databases for records up to March 2021. Peer-reviewed studies on adult populations that included instruments assessing prevalence and/or correlates of depression in Turkish and Moroccan immigrant populations met inclusion criteria and were assessed in terms of methodological quality. The review followed the relevant sections of the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) guideline.

RESULTS

We identified 51 relevant studies of observational design. Prevalence of depression was consistently higher among people who had an immigrant background, compared to those who did not. This difference seemed to be more pronounced for Turkish immigrants (especially older adults, women, and outpatients with psychosomatic complaints). Ethnicity and ethnic discrimination were identified as salient, positive, independent correlates of depressive psychopathology. Acculturation strategy (high maintenance) was related to higher depressive psychopathology in Turkish groups, while religiousness appeared protective in Moroccan groups. Current research gaps concern psychological correlates, second- and third-generation populations, and sexual and gender minorities.

CONCLUSION

Compared to native-born populations, Turkish immigrants consistently showed the highest prevalence of depressive disorder, while Moroccan immigrants showed similar to rather moderately elevated rates. Ethnic discrimination and acculturation were more often related to depressive symptomatology than socio-demographic correlates. Ethnicity seems to be a salient, independent correlate of depression among Turkish and Moroccan immigrant populations in Northwestern Europe.

A preliminary investigation of paranoia variability and its association with social functioning

Background

Paranoid ideation is a core feature of psychosis and is associated with impaired social functioning. Severity of paranoia can fluctuate across time as symptoms wax and wane; however, no study has systematically investigated how this intra-individual variability in paranoia may relate to social impairments and social functioning.

Methods

Fifty-five patients with DSM-5 diagnoses and recent paranoia were followed for up to one year and completed the suspiciousness/persecution section (P6) of the Positive and Negative Symptom Scale (PANSS) on a monthly basis to monitor fluctuations in paranoia. Categorical changes between paranoid and non-paranoid status were monitored and tallied. Participants self-reported current paranoia and anxiety levels as well as social functioning when demonstrating paranoia changes.

Results

Most patients showed changes between paranoid categories (60%). Individuals with no paranoia change showed higher current paranoia and lower independence-competence subscores of the Birchwood Social Functioning Scale (SFS) compared with those with one change. Current paranoia and state anxiety explained significant variance in the prosocial activities subscore of SFS, and importantly, paranoia changes accounted for variance above and beyond these effects. Individuals with higher current paranoia participated less in prosocial activities, however those with higher paranoia variability were more involved in social activities. Similarly, individuals with more paranoia variability demonstrated better overall social functioning as measured by the averaged SFS total score.

Conclusion

Paranoia fluctuation is prevalent across time, and both paranoia severity and variability impact social functioning, in that lower levels of paranoia severity and higher levels of paranoia variability are associated with better interpersonal functioning.

Three prominent self-report risk measures show unique and overlapping utility in characterizing those at clinical high-risk for psychosis

Self-report questionnaires have been developed to efficiently assess psychosis risk and vulnerability. Despite this, the validity of these questionnaires for assessing specific positive symptoms in those at clinical high risk for psychosis (CHR) is unclear. Positive symptoms have largely been treated as a uniform construct in this critical population and there have been no reports on the construct validity of questionnaires for assessing specific symptoms. The present study examined the convergent, discriminant, and criterion validity of the Launay Slade Hallucination Scale-Revised (LSHS-R), Prodromal Questionnaire-Brief (PQB), and Community Assessment of Psychic Experiences positive scale (CAPE-P) using a multimethod approach. CHR individuals (N = 71) and healthy controls (HC; N = 71) completed structured clinical interviews, self-report questionnaires, and neuropsychological tests. Questionnaire intercorrelations indicated strong convergent validity (i.e., all rs > .50); however, evidence for discriminant validity was more variable. In examining relations to interviewer-assessed psychosis symptoms, all questionnaires demonstrated evidence of criterion validity, though the PQB showed the strongest convergent correlations (e.g., r = .48 with total symptoms). In terms of discriminant validity for specific positive symptoms, results were again more variable. PQB subscales demonstrated limited specificity with positive symptoms, whereas CAPE-P subscales showed some specificity and the LSHS-R showed high specificity. In addition, when correlations with internalizing and externalizing symptoms were examined, only the PQB showed consistent significant correlations. These results are interpreted in terms of the strengths and limitations of each measure, their value for screening, and their potential utility for clarifying differences between specific positive symptoms.

Amygdala hyperconnectivity in the paranoid state: A transdiagnostic study

BACKGROUND

Paranoia significantly contributes to social impairments across clinical diagnoses, and amygdala dysfunction has been identified as a neurobiological marker of paranoia among individuals with schizophrenia. Therefore, we aimed to investigate amygdala functional connectivity (FC) in paranoia across diagnoses.

METHODS

Forty-five patients with recent history of clinically significant paranoid ideation and a current DSM-5 diagnosis of any disorder underwent resting-state functional magnetic resonance imaging either in a paranoid (N = 23) or non-paranoid (N = 22) state. Amygdala FC were compared between paranoid and non-paranoid patients. Supplemental correlation analyses between amygdala FC and paranoia score were performed separately in patients and a non-equivalent healthy control (HC; N = 60) group.

RESULTS

Increased FC was found between right amygdala and the prefrontal cortex (PFC) [bilateral medial superior frontal gyrus, anterior cingulate, medial frontal gyrus, the triangular part and the opercular part of the inferior frontal gyrus (IFG); right orbital part of IFG], the frontal cortex (bilateral median cingulate, left precentral gyrus), and subcortical areas (right insula) in the paranoid group compared with the non-paranoid group. No significant between-group differences were observed in left amygdala FC. FC between right amygdala and PFC and frontal cortex was positively correlated with paranoia in patient and HC groups.

CONCLUSION

Paranoia is associated with right amygdala hyperconnectivity with PFC, frontal cortex, and insula. This hyperconnectivity was evident regardless of diagnosis and therefore identify a likely transdiagnostic neural mechanism, which may help to identify treatment targets that could potentially improve the social functioning of individuals with clinical diagnoses.

Ethnicity and impact on the receipt of cognitive-behavioural therapy in people with psychosis or bipolar disorder: an English cohort study

OBJECTIVES

(1) To explore the role of ethnicity in receiving cognitive-behavioural therapy (CBT) for people with psychosis or bipolar disorder while adjusting for differences in risk profiles and symptom severity. (2) To assess whether context of treatment (inpatient vs community) impacts on the relationship between ethnicity and access to CBT.

DESIGN

Cohort study of case register data from one catchment area (January 2007-July 2017).

SETTING

A large secondary care provider serving an ethnically diverse population in London.

PARTICIPANTS

Data extracted for 30 497 records of people who had diagnoses of bipolar disorder (International Classification of Diseases (ICD) code F30-1) or psychosis (F20-F29 excluding F21). Exclusion criteria were: <15 years old, missing data and not self-defining as belonging to one of the larger ethnic groups. The sample (n=20 010) comprised the following ethnic groups: white British: n=10 393; Black Caribbean: n=5481; Black African: n=2817; Irish: n=570; and 'South Asian' people (consisting of Indian, Pakistani and Bangladeshi people): n=749.

OUTCOME ASSESSMENTS

ORs for receipt of CBT (single session or full course) as determined via multivariable logistic regression analyses.

RESULTS

In models adjusted for risk and severity variables, in comparison with White British people; Black African people were less likely to receive a single session of CBT (OR 0.73, 95% CI 0.66 to 0.82, p<0.001); Black Caribbean people were less likely to receive a minimum of 16-sessions of CBT (OR 0.83, 95% CI 0.71 to 0.98, p=0.03); Black African and Black Caribbean people were significantly less likely to receive CBT while inpatients (respectively, OR 0.76, 95% CI 0.65 to 0.89, p=0.001; OR 0.83, 95% CI 0.73 to 0.94, p=0.003).

CONCLUSIONS

This study highlights disparity in receipt of CBT from a large provider of secondary care in London for Black African and Caribbean people and that the context of therapy (inpatient vs community settings) has a relationship with disparity in access to treatment.

Sexual minority status and symptoms of psychosis: The role of bullying, discrimination, social support, and drug use - Findings from the Adult Psychiatric Morbidity Survey 2007

OBJECTIVE

Sexual minorities have an increased risk of psychosis, potentially explained by experiences of social adversity. Sexual minorities may also have a specific risk of paranoid symptoms. The current study aimed to determine whether sexual minorities have increased risk of psychosis, whether they have a specific increased risk of paranoia when compared to auditory verbal hallucinations (AVHs), and whether social adversity such as bullying, recent discrimination, lack of social support, and drug use can explain this risk.

METHODS

The study used data from the Adult Psychiatric Morbidity Survey 2007 (n = 7,403), exploring both sexual identity and past sexual behaviour. Associations between sexual minority status and probable psychosis, paranoia, and AVH were analysed using logistic regression. Mediation analysis was also conducted using the Karlson-Holm-Breen method, with bullying, recent discrimination, social support, and drug use as mediators assessing pathways between sexual minority status and paranoia/AVH. Socio-demographic confounders were included in analyses.

RESULTS

Sexual minority status did not significantly predict probable psychosis. Findings generally indicated a specific association between sexual minority status and paranoia when contrasted with AVH. However, sexual behaviour remained significantly associated with AVH in logistic regression models. Bullying, lack of social support, and drug use partially mediated the association between sexual minority status and paranoia.

CONCLUSIONS

Sexual minority status appears to have a specific association with paranoia symptoms, which may be partially explained by experiences of social adversity. However, the cross-sectional nature of the study limits direct inference about causality of such symptoms.

PRACTITIONER POINTS

Sexual minority groups may be more likely to experience symptoms of paranoia. It may be important to consider experiences of social adversity such as bullying, lack of social support, and also history of drug use in the context of paranoia within these groups.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): I. Psychosis superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a scientific effort to address shortcomings of traditional mental disorder diagnoses, which suffer from arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, heterogeneity within disorders, and diagnostic instability. This paper synthesizes evidence on the validity and utility of the thought disorder and detachment spectra of HiTOP. These spectra are composed of symptoms and maladaptive traits currently subsumed within schizophrenia, other psychotic disorders, and schizotypal, paranoid and schizoid personality disorders. Thought disorder ranges from normal reality testing, to maladaptive trait psychoticism, to hallucinations and delusions. Detachment ranges from introversion, to maladaptive detachment, to blunted affect and avolition. Extensive evidence supports the validity of thought disorder and detachment spectra, as each spectrum reflects common genetics, environmental risk factors, childhood antecedents, cognitive abnormalities, neural alterations, biomarkers, and treatment response. Some of these characteristics are specific to one spectrum and others are shared, suggesting the existence of an overarching psychosis superspectrum. Further research is needed to extend this model, such as clarifying whether mania and dissociation belong to thought disorder, and explicating processes that drive development of the spectra and their subdimensions. Compared to traditional diagnoses, the thought disorder and detachment spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and higher acceptability to clinicians. Validated measures are available to implement the system in practice. The more informative, reliable and valid characterization of psychosis-related psychopathology offered by HiTOP can make diagnosis more useful for research and clinical care.

Comparative exposure to antipsychotic medications in immigrant and native-born populations of a Spanish health region

Background

Raised rates of psychoses among ethnic minorities have been reported. Exposure to antipsychotic medications can give information on mental illness management and ethnic-related differences.

Objective

To compare exposure to antipsychotic medications in immigrant and native-born populations in Spain.

Method

Descriptive cross-sectional study of the dispensation of antipsychotic medications to the population aged 15 to 64 years, in a Spanish Health Region during 2008.

Results

1.9% of the native-born population was exposed to antipsychotic medications as compared to 0.4% of the immigrant population. Native-born women were exposed from 1.8 to 5.3 times more and native-born men from 3.6 to 6.3 times more than immigrants of the same gender. The least exposed were persons from Eastern Europe and men from sub-Saharan Africa. Active ingredients prescribed were similar between the two groups. Of the immigrant group, 15.7% were admitted to a psychiatric ward as compared to 6.4% of the native-born population. In the former, non-specific diagnoses were predominant.

Conclusions

All immigrant groups had lower exposure to antipsychotic medications, were admitted to inpatient care more often and had less specific diagnoses. Both diagnostic processes and adherence to treatment need improvement in the regional immigrant population.

Migration, ethnicity and psychoses: evidence, models and future directions

There is a large body of research reporting high rates of psychotic disorders among many migrant and minority ethnic groups, particularly in Northern Europe. In the context of increasing migration and consequent cultural diversity in many places worldwide, these findings are a major social and public health concern. In this paper, we take stock of the current state of the art, reviewing evidence on variations in rates of psychoses and putative explanations, including relevant theories and models. We discuss in particular: a) the wide variation in reported rates of psychotic disorders by ethnic group, and b) the evidence implicating social risks to explain this variation, at ecological and individual levels. We go on to set out our proposed socio-developmental model, that posits greater exposure to systemic social risks over the life course, particularly those involving threat, hostility and violence, to explain high rates of psychoses in some migrant and minority ethnic groups. Based on this analysis, the challenge of addressing this social and public health issue needs to be met at multiple levels, including social policy, community initiatives, and mental health service reform.

Psychopathology, cognition and outcome in Dutch and immigrant first-episode psychosis patients

AIM

The primary aim was to examine differences in baseline symptom expression, neurocognition, social cognition and psychosocial functioning between Dutch, first-generation immigrants and second-generation immigrants with a first-episode psychosis (FEP). The secondary aim was to examine functional and symptomatic change and between-group differences at 12-months follow-up. Associations between migration, baseline characteristics and outcome were explored.

METHODS

Forty-six Dutch, 56 second-generation- and 60 first-generation immigrant patients completed baseline measures for 6 symptom dimensions (positive symptoms, negative symptoms, neurocognitive functioning, social cognitive functioning, excitement and emotional distress) and 5 domains of psychosocial functioning (general functioning, work and study, relationships, self-care and disturbing behaviour). Functioning and psychotic symptoms were assessed at baseline and 12-months follow-up. ANCOVA and t tests were used to assess between-group differences. General linear models were used to explore within-group differences. Backward-regression was used to explore predictors of outcome.

RESULTS

Levels of positive symptoms, excitement and emotional distress did not differ between groups at baseline or follow-up. Dutch patients had lower levels of negative symptoms than both immigrant groups at follow-up. On neurocognition and social cognition, Dutch performed better than second-generation immigrants, who in turn performed better than first-generation immigrants. Psychosocial functioning across all domains at baseline and at 12-months follow-up was similar across groups. Baseline levels of general psychosocial functioning and income were the strongest predictors of outcome at follow-up.

CONCLUSIONS

Psychosocial functioning and symptom profiles are comparable between Dutch, first-generation immigrant and second-generation immigrant FEP patients, excluding neurocognitive and social cognitive deficits. A range of baseline characteristics predicted outcome.

Transdiagnostic dimensions of psychopathology at first episode psychosis: findings from the multinational EU-GEI study

BACKGROUND

The value of the nosological distinction between non-affective and affective psychosis has frequently been challenged. We aimed to investigate the transdiagnostic dimensional structure and associated characteristics of psychopathology at First Episode Psychosis (FEP). Regardless of diagnostic categories, we expected that positive symptoms occurred more frequently in ethnic minority groups and in more densely populated environments, and that negative symptoms were associated with indices of neurodevelopmental impairment.

METHOD

This study included 2182 FEP individuals recruited across six countries, as part of the EUropean network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) study. Symptom ratings were analysed using multidimensional item response modelling in Mplus to estimate five theory-based models of psychosis. We used multiple regression models to examine demographic and context factors associated with symptom dimensions.

RESULTS

A bifactor model, composed of one general factor and five specific dimensions of positive, negative, disorganization, manic and depressive symptoms, best-represented associations among ratings of psychotic symptoms. Positive symptoms were more common in ethnic minority groups. Urbanicity was associated with a higher score on the general factor. Men presented with more negative and less depressive symptoms than women. Early age-at-first-contact with psychiatric services was associated with higher scores on negative, disorganized, and manic symptom dimensions.

CONCLUSIONS

Our results suggest that the bifactor model of psychopathology holds across diagnostic categories of non-affective and affective psychosis at FEP, and demographic and context determinants map onto general and specific symptom dimensions. These findings have implications for tailoring symptom-specific treatments and inform research into the mood-psychosis spectrum.

Comparison between a morocco and a native-born population, in a sample of first episode psychosis

INTRODUCTION

Ethnic differences have been studied previously in schizophrenia and first episodes of psychosis (FEP). Previous studies in Netherlands have reported a higher incidence of psychosis in male Moroccan immigrants and more clinical severity. However there is lack of studies in Spain with morocco population and FEP.

OBJECTIVES

This study aims to determine the clinical differences in a sample of FEP between Morocco and Spanish population, recruited in a hospitalisation unit.

MATERIAL AND METHODS

Descriptive and cross-sectional study of 83 inpatients (FEP). Functionality and symptomatology were evaluated at entry and discharge, the pattern of use of cannabis was evaluated at entry, the dose of antipsychotic and the pattern of side-effects at discharge. Comparisons between native-born population and Morocco population was made with univariate analysis and logistic regression was made for evaluating the independence of the associations.

RESULTS

The 28.9% of the sample was Morocco group. No significance differences were found in clinical characteristics between groups at entry or at discharge. Compared with native-born, the Morocco group were more male, with less years of education, worse functionality, reported less use of cannabis, a better pattern of side effects and a tendency of more prescription of LAis. After the multivariate analysis, just remains a lower functionality (OR 0.93; IC 95%: 0.88-0.99, P=0.02) and lower years of education (OR 0.75; IC 95%: 0.56-1.01, P=0.05), remain significative with being related with Morocco origin.

CONCLUSIONS

Our study provides evidence for ethnic differences in Morocco population with FEP. Patients with Morocco ethnicity have more probability of being males, less years of educations. Have lower functionality and a better profile of side effects.

Ethnic minority position and migrant status as risk factors for psychotic symptoms in the general population: a meta-analysis

Psychotic symptoms (PS) are experienced by a substantial proportion of the general population. When not reaching a threshold of clinical relevance, these symptoms are defined as psychotic experiences (PEs) and may exist on a continuum with psychotic disorders. Unfavorable socio-environmental conditions, such as ethnic minority position (EMP) and migrant status (MS), may increase the risk of developing PS and PEs. We conducted an electronic systematic review and a meta-analysis assessing the role of EMP and MS for the development and persistence of PS in the general population. Sub-group analyses were performed investigating the influence of ethnic groups, host countries, age, types of PS, and scales. Twenty-four studies met our inclusion criteria. EMP was a relevant risk factor for reporting PS [odds ratio (OR) 1.44, 95% confidence interval (CI) 1.22-1.70) and PEs (OR 1.36, 95% CI 1.16-1.60). The greatest risk was observed in people from the Maghreb and the Middle East ethnic groups in Europe (OR 3.30, 95% CI 2.09-5.21), in Hispanic in the USA (OR 1.98, 95% CI 1.43-2.73), and in the Black populations (OR 1.85, 95% CI 1.39-2.47). We found a significant association between MS and delusional symptoms (OR 1.47, 95% CI 1.33-1.62). We found no association between EMP and persistence of PEs.EMP was associated with increased risk of reporting PS and PEs, and the risk was higher in ethnic groups facing deprivation and discrimination. We found an association between MS and delusional symptoms. These results raise questions about the precise role of socio-environmental factors along the psychosis continuum.

Transdiagnostic dimensions of psychosis in the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP)

The validity of the classification of non-affective and affective psychoses as distinct entities has been disputed, but, despite calls for alternative approaches to defining psychosis syndromes, there is a dearth of empirical efforts to identify transdiagnostic phenotypes of psychosis. We aimed to investigate the validity and utility of general and specific symptom dimensions of psychosis cutting across schizophrenia, schizoaffective disorder and bipolar I disorder with psychosis. Multidimensional item-response modeling was conducted on symptom ratings of the Positive and Negative Syndrome Scale, Young Mania Rating Scale, and Montgomery-Åsberg Depression Rating Scale in the multicentre Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) consortium, which included 933 patients with a diagnosis of schizophrenia (N=397), schizoaffective disorder (N=224), or bipolar I disorder with psychosis (N=312). A bifactor model with one general symptom dimension, two distinct dimensions of non-affective and affective psychosis, and five specific symptom dimensions of positive, negative, disorganized, manic and depressive symptoms provided the best model fit. There was further evidence on the utility of symptom dimensions for predicting B-SNIP psychosis biotypes with greater accuracy than categorical DSM diagnoses. General, positive, negative and disorganized symptom dimension scores were higher in African American vs. Caucasian patients. Symptom dimensions accurately classified patients into categorical DSM diagnoses. This study provides evidence on the validity and utility of transdiagnostic symptom dimensions of psychosis that transcend traditional diagnostic boundaries of psychotic disorders. Findings further show promising avenues for research at the interface of dimensional psychopathological phenotypes and basic neurobiological dimensions of psychopathology.

Investigating ethnic variations in reporting of psychotic symptoms: a multiple-group confirmatory factor analysis of the Psychosis Screening Questionnaire

BACKGROUND

Epidemiological evidence suggests risk for psychosis varies with ethnicity in Western countries. However, there is little evidence to date on the cross-cultural validity of screening instruments used for such comparisons.

METHODS

Combining two existing UK population-based cohorts, we examined risk for reporting psychotic symptoms across White British (n = 3467), White Irish (n = 851), Caribbean (n = 1899), Indian (n = 2590), Pakistani (n = 1956) and Bangladeshi groups (n = 1248). We assessed the psychometric properties of the Psychosis Screening Questionnaire (PSQ) with a multiple-group confirmatory factor analysis, assessing the equivalence of factor loadings, response thresholds and residual variances in an analysis of measurement non-invariance.

RESULTS

Compared with prevalence among British Whites (5.4%), the prevalence of self-reported psychotic symptoms was greater in the Caribbean group (12.7%, adjusted OR = 2.38 [95% CI 1.84-3.07]). Prevalence was also increased among Pakistani individuals (8.3%, adjusted OR = 1.36 [1.01-1.84]) although this difference was driven by a greater likelihood of reporting paranoid symptoms. PSQ items for thought interference, strange experience and hallucination were measured in equivalent ways across ethnic groups. However, our measurement models suggested that paranoid symptoms were measured less reliably among ethnic minorities than among British Whites and appeared to exaggerate latent differences between Pakistani and White British groups when measurement non-invariance was not accounted for.

CONCLUSIONS

Notwithstanding evidence for measurement non-invariance, the greater risk for reporting psychotic symptoms among Caribbean individuals is unlikely to be an artefact of measurement. Greater residual variance in the recording of paranoid symptoms among ethnic minority respondents warrants caution in using this item to investigate ethnic variation in psychosis risk.

Amygdala reactivity in ethnic minorities and its relationship to the social environment: an fMRI study

BACKGROUND

Ethnic minority individuals have an increased risk of developing a psychotic disorder, particularly if they live in areas of ethnic segregation, or low own group ethnic density. The neurobiological mechanisms underlying this ethnic minority associated risk are unknown. We used functional MRI to investigate neural responses to faces of different ethnicity, in individuals of black ethnicity, and a control group of white British ethnicity individuals.

METHODS

In total 20 individuals of black ethnicity, and 22 individuals of white British ethnicity underwent a 3T MRI scan while viewing faces of black and white ethnicity. Own group ethnic density was calculated from the 2011 census. Neighbourhood segregation was quantified using the Index of Dissimilarity method.

RESULTS

At the within-group level, both groups showed greater right amygdala activation to outgroup faces. Between groups, the black ethnicity group showed greater right amygdala activation to white faces, compared to the white ethnicity group. Within the black ethnicity group, individuals living in areas of lower own group ethnic density showed greater right amygdala reactivity to white faces (r = -0.61, p = 0.01).

CONCLUSIONS

This is the first time an increased amygdala response to white faces has been demonstrated in individuals of black ethnicity. In the black ethnicity group, correlations were observed between amygdala response and neighbourhood variables associated with increased psychosis risk. These results may have relevance for our understanding of the increased rates of paranoia and psychotic disorders in ethnic minority individuals.

Ethnic variations regarding clinical profiles and symptom representation in prisoners with psychotic disorders

BACKGROUND

Black and minority ethnic (BME) groups are known to have higher prevalences of psychotic disorders and are over-represented in western penitentiaries and forensic psychiatric institutions. Research from regular mental healthcare settings suggests that they could show different and more severe psychotic symptoms. Aims To explore ethnic variations in severity of symptomatology of BME and non-BME detainees with psychotic disorders.

METHOD

In this study, 824 patients with psychotic disorders from seven different ethnic groups, imprisoned in a penitentiary psychiatric centre in the Netherlands, were compared on symptom severity and symptom representation using the BPRS-E clinical interview. Data were analysed by means of a multilevel analysis.

RESULTS

BME patients with psychotic disorders are over-represented in forensic psychiatry, and symptom profiles of prisoners with psychotic disorders vary by ethnicity. Additionally, severity levels of overall psychopathology differ between ethnic groups: patients with an ethnic majority status show more severe levels of psychopathology compared with BME patients.

CONCLUSIONS

There are differences in symptom severity and symptom profiles between BME patients and non-BME patients. Disregarding these differences could have an adverse effect on the outcome of the treatment. Possible explanations and clinical impact are discussed. Declaration of interest None.

Social exclusion and psychopathology in an online cohort of Moroccan-Dutch migrants: Results of the MEDINA-study

Introduction

Migration is seen as a risk factor for developing psychiatric symptoms and experiencing social exclusion. In the Netherlands, the Moroccan-Dutch population is the second largest migrant group. 70% of all young Moroccan-Dutch people meet each other in the online community www.marokko.nl. Within this community, we investigated the association between experiences of social exclusion and self-reported depressive symptoms and psychotic experiences.

Materials and methods

Participants were recruited via the website www.marokko.nl. They completed an online survey, with screening instruments for depressive symptoms (K10) and psychotic experiences (PQ-16), measures of social exclusion (perceived discrimination, social defeat and social support), and questions about demographical information. With regression analysis the association between social exclusion and psychiatric symptoms was investigated.

Results

We included 267 participants; 87% were female. 27% of the sample has received mental healthcare in the past. Over 50% of these people screened positive for depressive symptoms and psychotic experiences. Perceived discrimination and social defeat were significantly associated with psychotic experiences and social defeat was associated with depressive symptoms. Social support and higher education were associated with less depressive symptoms and psychotic experiences.

Discussion

Our findings suggest that the online environment allows for epidemiological research and early symptom detection. Levels of psychopathology were high in our sample. This suggests that a part of this young ethnic minority population might not get adequate mental healthcare. Since this population can be reached through Internet, the online environment may therefore also offer an appropriate setting for intervention, to increase resilience towards social exclusion.

Symptom profiles and explanatory models of first-episode psychosis in African-, Caribbean- and European-origin groups in Ontario

AIM

To assess variability in symptom presentation and explanatory models of psychosis for people from different ethnic groups.

METHODS

Clients with first-episode psychosis (n = 171) who identified as black African, black Caribbean or white European were recruited from early intervention programmes in Toronto and Hamilton. We compared results by ethnic group for symptom profiles and explanatory models of illness.

RESULTS

Clients of black Caribbean origin had a lower odds of reporting that they were speaking incomprehensibly (OR = 0.36; 95% CI: 0.14-0.90) and black African clients had a greater odds of reporting persistent aches or pains (OR = 2.92; 95% CI: 1.32-6.50). Black African clients had a lower odds of attributing the cause of psychosis to hereditary factors (OR = 0.41; 95% CI: 0.19-0.89) or to substance abuse (OR = 0.29; 95% CI: 0.13-0.67) and had a lower odds of assigning responsibility for their illness to themselves (OR = 0.41; 95% CI: 0.19-0.89).

CONCLUSIONS

Understanding the differences in illness models for ethnic minority groups may help improve the cultural competence of mental health services.

PARANOID INDIVIDUALS WITH SCHIZOPHRENIA SHOW GREATER SOCIAL COGNITIVE BIAS AND WORSE SOCIAL FUNCTIONING THAN NON-PARANOID INDIVIDUALS WITH SCHIZOPHRENIA

Paranoia is a common symptom of schizophrenia that may be related to how individuals process and respond to social stimuli. Previous investigations support a link between increased paranoia and greater social cognitive impairments, but these studies have been limited to single domains of social cognition, and no studies have examined how paranoia may influence functional outcome. Data from 147 individuals with schizophrenia were used to examine whether actively paranoid and non-paranoid individuals with schizophrenia differ in social cognition and functional outcomes. On measures assessing social cognitive bias, paranoid individuals endorsed more hostile and blaming attributions and identified more faces as untrustworthy; however, paranoid and non-paranoid individuals did not differ on emotion recognition and theory of mind tasks assessing social cognitive ability. Likewise, paranoid individuals showed greater impairments in real-world interpersonal relationships and social acceptability as compared to non-paranoid patients, but these differences did not extend to performance based tasks assessing functional capacity and social competence. These findings isolate specific social cognitive disparities between paranoid and non-paranoid subgroups and suggest that paranoia may exacerbate the social dysfunction that is commonly experienced by individuals with schizophrenia.

Origin and schizophrenia in young refugees and inter-country adoptees from Latin America and East Africa in Sweden: a comparative study

BACKGROUND

Migrants' socioeconomic adversity has been linked to schizophrenia.

AIMS

To investigate whether the more favourable socioeconomic situation of adoptees prevents them from the high risk of schizophrenia found in other migrants.

METHOD

Register study in a cohort of refugees and inter-country adoptees aged 16-40 years, born in East Africa (n=8389), Latin America (n=11 572) and 1.2 million native Swedes. Cox-regression models estimated hazard ratios (HRs) of schizophrenia in data from psychiatric care.

RESULTS

Despite diverse income levels, HRs for schizophrenia were similar for refugees and adoptees, with East Africans having the highest HRs: 5.83 (3.30-10.27) and 5.80 (5.03-6.70), followed by Latin Americans: HRs 3.09 (2.49-3.83) and 2.31 (1.79-2.97), compared with native Swedes. Adjustment for income decreased these risks slightly for refugees, but not for adoptees.

CONCLUSIONS

This study suggests that risk factors associated with origin are more important determinants of schizophrenia than socioeconomic adversity in the country of settlement.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© 2016 The Royal College of Psychiatrists. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

The impact of immigration and visible minority status on psychosis symptom profile

PURPOSE

Immigrants have heightened risks of psychotic disorders, and it is proposed that migration influences symptom profiles. The purpose of this study was to investigate if either migration experience and/or visible minority status affected symptom profiles, using a cross-culturally validated five-factor model of the Positive and Negative Syndrome Scale (PANSS), in patients with broadly defined psychotic disorders.

METHODS

PANSS was assessed in a large catchment area based sample of patients with psychotic disorders verified with the Structured Clinical Interview for DSM-IV (n = 1,081). Symptom profiles based on Wallwork et al. five-factor model were compared for Norwegians (73 %), white immigrants (10.5 %), and visible minority groups (16.5 %).

RESULTS

Visible minorities were significantly younger, had less education, more often a schizophrenia diagnosis and higher PANSS positive, negative and disorganized/concrete factor scores than Norwegians and white immigrants. After controlling for confounders only the items "Delusions" and "Difficulty in abstract thinking" differed between groups. Multivariate analyses indicated that these items were not associated with immigration per se, but rather belonging to a visible minority.

CONCLUSION

We found mostly similarities in psychotic symptoms between immigrants and Norwegians when using a cross-culturally validated five-factor model of the PANSS. Immigration did not directly influence psychotic symptom profiles but visible minority groups had higher levels of "Delusions" and "Difficulty in abstract thinking", both symptoms that are partially context dependent.

A meta-analysis of ethnic differences in pathways to care at the first episode of psychosis

OBJECTIVE

We sought to systematically review the literature on ethnic differences in the likelihood of general practitioner (GP) involvement, police involvement, and involuntary admission on the pathway to care of patients with first-episode psychosis (FEP).

METHOD

We searched electronic databases and conducted forward and backward tracking to identify relevant studies. We calculated pooled odds ratios (OR) to examine the variation between aggregated ethnic groups in the indicators of the pathway to care.

RESULTS

We identified seven studies from Canada and England that looked at ethnic differences in GP involvement (n=7), police involvement (n=7), or involuntary admission (n=5). Aggregated ethnic groups were most often compared. The pooled ORs suggest that Black patients have a decreased likelihood of GP involvement (OR=0.70, 0.57-0.86) and an increased likelihood of police involvement (OR=2.11, 1.67-2.66), relative to White patients. The pooled ORs were not statistically significant for patients with Asian backgrounds (GP involvement OR=1.23, 0.87-1.75; police involvement OR=0.86, 0.57-1.30). There is also evidence to suggest that there may be ethnic differences in the likelihood of involuntary admission; however, effect modification by several sociodemographic factors precluded a pooling of these data.

CONCLUSION

Ethnic differences in pathways to care are present at the first episode of psychosis.

The Concept of Schizophrenia: From Unity to Diversity

After over 100 years of research without clarifying the aetiology of schizophrenia, a look at the current state of knowledge in epidemiology, genetics, precursors, psychopathology, and outcome seems worthwhile. The disease concept, created by Kraepelin and modified by Bleuler, has a varied history. Today, schizophrenia is considered a polygenic disorder with onset in early adulthood, characterized by irregular psychotic episodes and functional impairment, but incident cases occur at all ages with marked differences in symptoms and social outcome. Men’s and women’s lifetime risk is nearly the same. At young age, women fall ill a few years later and less severely than men, men more rarely and less severely later in life. The underlying protective effect of oestrogen is antagonized by genetic load. The illness course is heterogeneous and depressive mood the most frequent symptom. Depression and schizophrenia are functionally associated, and affective and nonaffective psychoses do not split neatly. Most social consequences occur at the prodromal stage. Neither schizophrenia as such nor its main symptom dimensions regularly show pronounced deterioration over time. Schizophrenia is neither a residual state of a neurodevelopmental disorder nor a progressing neurodegenerative process. It reflects multifactorial CNS instability, which leads to cognitive deficits and symptom exacerbations.

A systematic review of ethnic variations in hospital admission and compulsory detention in first-episode psychosis

BACKGROUND

Marked ethnic variations in incidence, pathways to care and outcomes have been demonstrated in psychosis. Less research has focused specifically on first-episode psychosis (FEP), particularly adverse contacts such as compulsory detention and hospitalization. This is despite international initiatives to promote equity of care and active early intervention.

AIM

Systematically review current evidence for ethnic variations in rates of compulsory admission and hospitalization in FEP.

METHODS

Relevant articles published before December 2012 were identified from PubMed, PSYCInfo, and CINAHL together with manual searching of reference lists. Studies providing quantitative data on compulsory detention rates and/or hospitalization, comparing ethnic groups in FEP, were included and quality rated by independent raters.

RESULTS

All included studies (n = 7) provided data on compulsory detention while fewer (n = 3) focused on admission rates. Three studies reported increased detention in Black and minority ethnic groups, while one reported more hospitalization in White patients. Only two studies covered early intervention services (EIS).

CONCLUSIONS

There is a paucity of high quality, well powered studies addressing this important issue, especially in EIS settings. In order to best inform and evaluate fast-developing services, it will be essential to combine large methodologically robust studies with qualitative analysis of patient, carer, and staff experiences.

Race, ethnicity, and the duration of untreated psychosis: a systematic review

PURPOSE

An extended duration of untreated psychosis (DUP) is associated with poor outcome in first-episode psychosis (FEP). Some have suggested that minority ethnic groups have longer treatment delays, and this could lead to worse outcomes. We systematically reviewed the literature on racial and ethnic differences in DUP in patients with FEP.

METHODS

We searched electronic databases and conducted forward and backward tracking to identify studies that had compared DUP for people with FEP from different racial or ethnic groups.

RESULTS

We identified ten papers that reported on the association between race or ethnicity and DUP. Overall, these studies did not find evidence of differences between groups; however, three of ten studies suggested that Black patients generally, and Black-African patients specifically, may have a shorter DUP relative to White patients. There were methodological limitations in most studies with respect to ethnicity classification, sample size, and adjustment for potential confounders.

CONCLUSION

Racial and ethnic differences in DUP were rarely found. This could reflect that DUP does not differ between groups, or may reflect the methodological limitations of prior research. Studies that are designed and powered to examine these differences in treatment delay are needed to determine whether there are differences in DUP for minority groups.

Clinical symptoms of psychotic episodes and 25-hydroxy vitamin D serum levels in black first-generation immigrants

OBJECTIVE

Dark-skinned immigrants have a higher risk for schizophrenia and other psychoses than other immigrants. The first British studies reported that first-generation immigrants (FGIs) from the Caribbean presented atypical psychoses. This study examines the characteristics of psychotic episodes in black FGIs to Canada.

METHOD

The charts of 18 FGIs from Africa and Haiti, extracted from a series of 20 black patients consecutively admitted to Psychiatry, were retrospectively reviewed regarding clinical features, diagnoses and vitamin D levels.

RESULTS

Young FGIs presented acute psychotic episodes with abrupt onset, florid positive symptoms, few negative symptoms and good evolution. The onset was more insidious in older FGIs. Overall, catatonia was very frequent (28%), and mood symptoms still more frequent (44%). No cognitive decline was observed during follow-up. Serum levels of 25-hydroxy vitamin D were in the insufficiency range. Supplementation at 1000 IU/day did not restore normal levels.

CONCLUSION

The clinical features of psychotic episodes in black FGIs are similar to those reported in dark-skinned FGIs to other countries. They are also observed in other immigrants and in non-immigrants. These atypical psychoses are possibly related to a recent vitamin D deficit. This hypothesis should be tested by clinical trials of sufficient vitamin D supplementation.

Acculturative stress and psychotic-like experiences among Asian and Latino immigrants to the United States

Previous studies have shown variation in the prevalence and incidence of psychosis across immigrant groups, but the underlying mechanisms are not fully understood. Stress related to acculturation may increase risk for psychosis among immigrant groups. In this study we examine the association between acculturative stress and psychotic-like experiences in a sample of Latino- and Asian-American immigrants to the United States in the National Latino and Asian American Study (n=2434). Acculturative stress was associated with visual and auditory hallucinations among Asians, but only with hearing voices among Latinos. Increased risk for psychotic-like experiences among Latinos was primarily associated with younger age of immigration. Acculturative stress appears to be a promising candidate mechanism explaining the relationship between immigration and psychosis, particularly among Asian Americans. Ethnic differences may reflect variability between groups that integrate more readily into the host culture and those that are subject to greater discrimination and environmental adversity.

A study of acculturation in psychotic and non-psychotic immigrants living in Athens

BACKGROUND

Acculturation is the phenomenon that results when a group with one culture comes into continuous contact with a host culture.

AIMS

To investigate the correlation between acculturation and psychotic symptomatology in a group of immigrants suffering from psychosis and to explore differences in demographic factors related with the acculturation process between individuals with and without psychosis.

METHODS

Sixty-five patients and 317 non-psychotic immigrants were interviewed using the Immigrant Acculturation Scale (IAS) and a structured questionnaire for demographic data. The Positive and Negative Syndrome Scale (PANSS), the Calgary Depression Scale for Schizophrenia (CDSS) and the Global Assessment of Functioning (GAF) were also administered to all immigrants suffering from psychosis.

RESULTS

Total IAS scores, as well as IAS everyday life scores, were positively correlated with GAF scores. IAS everyday life score in the patient group related with religion, marital status, gender and years in Greece, while in the non-psychosis group it was related with gender and years in Greece. IAS wishful orientation/nostos (the strong desire for one's homeland) related with religion in both groups. The IAS identity in the psychosis group did not show any significant relation with any of the variables, while in the non-patient group, it was related with marital status, gender and years in Greece. Age, duration of residence in Greece and higher adoption of Greek ethnic identity were the variables that differentiated the two groups of immigrants.

CONCLUSION

Acculturation in immigrants suffering from psychosis could be seen as a process that does not correlate strongly with the severity of the symptomatology but is probably influenced by different set of factors.

Cognitive deficits and ethnicity: a cohort study of early psychosis patients in The Netherlands

PURPOSE

Incidence rates of psychotic disorders are higher in immigrant groups compared to native populations. This increased risk may partly be explained by misdiagnosis. Neurocognitive deficits are a core feature of psychotic disorders, but little is known about the relationship between migration and cognition in psychotic disorders. We examined whether immigrant patients have cognitive deficits similar to non-immigrant patients, in order to investigate the plausibility of misdiagnosis as explanation for increased incidence rates.

METHODS

Patients who made first contact for non-affective psychotic disorder were assessed in the cognitive domains sustained attention, immediate recall and delayed recall. Immigrant patients were compared to Dutch patients on cognitive performance.

RESULTS

407 Patients diagnosed with a non-affective psychotic disorder completed cognitive assessment (157 Dutch, 250 immigrants). Both Dutch and immigrant patients showed large cognitive deficits. Between-subgroup comparisons revealed large cognitive deficits for immigrants compared to Dutch, especially for immigrants from Morocco, Turkey and other non-Western countries.

CONCLUSIONS

These results indicate that immigrant status is associated with poorer cognitive functioning in early psychosis. The findings argue against diagnostic bias as an explanation for the increased incidence of psychotic disorders in immigrants.

Comparing the clinical presentation of first-episode psychosis across different migrant and ethnic minority groups in Montreal, Quebec

OBJECTIVE

To explore differences in severity and nature of symptoms of first-episode psychosis (FEP) according to ethnic group and migrant status.

METHOD

We administered rating scales to assess positive and negative symptoms, as well as general psychopathology, to 301 consecutive patients presenting with an FEP within a defined catchment area in Montreal, Quebec, classified according to ethnicity and migrant status. Symptom scores of Euro-Canadian patients without a recent history of migration, that is, the reference group (n = 145), were compared with those of African and Afro-Caribbean (n = 39), Asian (n = 27), Central and South American (n = 15), Middle Eastern and North African (n = 24), and European and North American (n = 39) patients.

RESULTS

Except for referral source, there were no significant differences between ethnic groups on any demographic variables. The African and Afro-Caribbean group had a higher level of negative symptoms (especially alogia) and general psychopathology scores on the Positive and Negative Syndrome Scale (especially, uncooperativeness, preoccupation, and poor attention), compared with the reference group. Ethnic groups did not differ on the Scale for the Assessment of Positive Symptoms scores.

CONCLUSIONS

A comparison of FEP patients from different ethnic groups and native-born Euro-Canadians revealed no significant differences in the nature of positive symptoms at first presentation or in age at onset, suggesting that there was no evidence for the hypothesis that ethnic minorities are misdiagnosed as psychotic. Increased severity of negative symptoms and general psychopathology, specifically among the black ethnic minority group, may have implications for the role of ethnicity for the treatment and outcome of the initial episode of psychotic disorders.

Ethnicity and baseline symptomatology in patients with an At Risk Mental State for psychosis

BACKGROUND

Ethnicity has been associated with different incidence rates and different symptom profiles in young patients with psychotic-like disorders. No studies so far have examined the effect of ethnicity on symptoms in people with an At Risk Mental State (ARMS).

METHOD

In this cross-sectional study, we analysed the relationship between ethnicity and baseline data on the severity of psychopathology scores in 201 help-seeking patients who met the ARMS criteria and agreed to participate in the Dutch Early Detection and Intervention (EDIE-NL) trial. Eighty-seven of these patients had a non-Dutch ethnicity. We explored the possible mediating role of ethnic identity.

RESULTS

Higher rates of negative symptoms, and of anhedonia in particular, were found in the ethnic minority group. This result could be attributed mainly to the Moroccan-Dutch and Turkish-Dutch subgroups, who also presented with more depression symptoms when the groups were examined separately. The ethnic minority group displayed a lower level of ethnic group identity compared to the immigrants of the International Comparative Study of Ethnocultural Youth (ICSEY). Ethnic identity was inversely related to symptoms in the Moroccan-Dutch patient group.

CONCLUSIONS

The prevalence of more severe negative symptoms and depression symptoms in ethnic minority groups deserves more attention, as the experience of attenuated positive symptoms when accompanied by negative symptoms or distress has proven to be predictive for transition to a first psychotic episode.

Ethnic differences in risk of acute compulsory admission in Amsterdam, 1996-2005

PURPOSE

Several European studies have shown that migrants from non-western countries are at increased risk of psychotic disorders. This study examines how this is reflected in the risk of acute compulsory admission (ACA).

METHODS

Information on all patients with an ACA in Amsterdam from 1996 to 2005 was linked to the Amsterdam municipal register.

RESULTS

The incidence of first ACA in Amsterdam was 4.5 per 10,000 person years. The incidence risk of ACA for any psychiatric disorders and for psychotic disorders in particular showed a 2- to 3-fold increase in almost all migrant groups from non-western countries, and especially for second-generation migrants. In addition, all non-western migrant groups were at increased risk of being assessed as posing a danger to others.

CONCLUSIONS

The relative risk of ACA for psychotic disorders was similar to that for the incidence of psychotic disorders in most ethnic groups from other studies, suggesting that the increased risk of ACA in non-western migrants can mainly be explained by the increased incidence of psychotic disorders in these groups. However, the relative risk of ACA for psychotic disorders among Moroccan migrants was lower than expected on the basis of incidence studies, which suggests that additional factors are relevant, such as illness-related expression and access to and quality of care.

Cross-ethnic differences in severity of symptomatology of individuals with first-episode schizophrenia spectrum disorder

AIMS

The aims of this study were to describe the relationship between ethnicity and severity of baseline symptomatology in a sample of Asian individuals with first-episode schizophrenia spectrum disorder, and to determine if ethnicity predicts severity of symptomatology independent of gender, duration of untreated illness, premorbid functioning, and age of illness onset.

METHODS

This descriptive study included all Chinese, Malay and Indian individuals consecutively admitted into an early intervention programme for treatment of first-episode schizophrenia spectrum disorder. Comparisons of mean scores among the three ethnic groups were performed using analysis of variance, while chi-squared tests were used to compare proportions. Subsequent pair-wise comparisons were performed with Bonferroni corrected statistic to examine specific ethnic group differences. Multivariate regression analyses were conducted to identify factors significantly associated with the severity of different clinical dimensions of schizophrenia measured using the Positive and Negative Syndrome Scale (PANSS).

RESULTS

The analyses involved 503 individuals. The mean PANSS scores were significantly different between the ethnic groups across the PANSS subscales. A post-hoc analysis showed that Malays scored significantly higher than Chinese did across the PANSS subscales. Malays also scored significantly higher than Indians did on the negative scale and the general psychopathology scale. Being Malay compared with Chinese consistently predicted more severe positive, negative and general psychopathology symptoms.

DISCUSSION

The results indicated that the severity of baseline symptomatology of individuals with first-episode schizophrenia spectrum disorders differed by ethnicity. Premorbid functioning appears to act as a potential mediator of the effects of ethnicity on the severity of psychotic symptoms.

Migration and psychotic disorders

The incidence of psychotic disorders is extremely high in several immigrant groups in Europe. This article describes the epidemiological evidence for increased incidence rates among immigrants compared with nonimmigrant populations and explores possible explanations for this excess risk. Potential causes not only involve factors acting at the level of the individual, but encompass the broader social context of neighborhoods and ethnic groups. Growing up and living in a disadvantaged ethnic minority position, characterized by a low social status, high degree of discrimination against the group and low neighborhood ethnic density, may lead to an increased risk of psychotic disorders, especially when individuals reject their minority status and when their social resources are insufficient to buffer the impact of adverse social experiences. Future research should refine measures of the social context, adopt a life-course perspective and should integrate social and neurobiological pathways.

Perceived discrimination is associated with severity of positive and depression/anxiety symptoms in immigrants with psychosis: a cross-sectional study

BACKGROUND

Immigration status is a significant risk factor for psychotic disorders, and a number of studies have reported more severe positive and affective symptoms among immigrant and ethnic minority groups. We investigated if perceived discrimination was associated with the severity of these symptoms among immigrants in Norway with psychotic disorders.

METHODS

Cross-sectional analyses of 90 immigrant patients (66% first-generation, 68% from Asia/Africa) in treatment for psychotic disorders were assessed for DSM-IV diagnoses with the Structured Clinical Interview for DSM Disorders (SCID-I, sections A-E) and for present symptom severity by The Structured Positive and Negative Syndrome Scale (SCI-PANSS). Perceived discrimination was assessed by a self-report questionnaire developed for the Immigrant Youth in Cultural Transition Study.

RESULTS

Perceived discrimination correlated with positive psychotic (r=0.264, p<0.05) and depression/anxiety symptoms (r=0.282, p<0.01), but not negative, cognitive, or excitement symptoms. Perceived discrimination also functioned as a partial mediator for symptom severity in African immigrants. Multiple linear regression analyses controlling for possible confounders revealed that perceived discrimination explained approximately 10% of the variance in positive and depression/anxiety symptoms in the statistical model.

CONCLUSIONS

Among immigrants with psychotic disorders, visible minority status was associated with perceived discrimination and with more severe positive and depression/anxiety symptoms. These results suggest that context-specific stressful environmental factors influence specific symptom patterns and severity. This has important implications for preventive strategies and treatment of this vulnerable patient group.

High rates of psychosis for black inpatients in Padua and Montreal: different contexts, similar findings

OBJECTIVE

This study tested the hypothesis that despite differences in setting, specifically in Padua or Montreal, black psychiatric inpatients will have higher rates of assigned diagnosis of psychosis than their non-black counterparts.

METHODS

Data on psychotic patients admitted to the psychiatry ward were extracted from records of general hospitals in Padua and Montreal. Logistic regression analyses were conducted separately for each site to determine the relation between being black and receiving a diagnosis of psychosis, while controlling for sex and age.

RESULTS

Most black patients at both sites received a diagnosis of psychosis (76% in Padua and 81% in Montreal). Being black was independently and positively associated with being diagnosed with psychosis compared to patients from other groups.

CONCLUSIONS

Black patients admitted to psychiatry, whether in Padua or Montreal, were more likely to be assigned a diagnosis of psychosis than were other patients.

A single blind randomized controlled trial of cognitive behavioural therapy in a help-seeking population with an At Risk Mental State for psychosis: the Dutch Early Detection and Intervention Evaluation (EDIE-NL) trial

Background

Psychotic disorders are a serious mental health problem. Intervention before the onset of psychosis might result in delaying the onset, reducing the impact or even preventing the first episode of psychosis. This study explores the effectiveness of cognitive behavioural therapy (CBT) in targeting cognitive biases that are involved in the formation of delusions in persons with an ultra-high risk for developing psychosis. A single blind randomised controlled trial compares CBT with treatment as usual in preventing or delaying the onset of psychosis.

Method/design

All help seeking patients aged 14 to 35 years referred to the mental health services in three regions in the Netherlands are pre-screened with the Prodromal Questionnaire during a period of two years. Patients with a score of 18 or more on the sub-clinical positive symptoms items (45 items in total) will be assessed with the Comprehensive Assessment of At Risk Mental State (CAARMS). In a different pathway to care model all referrals from the mental health services in Amsterdam to the specialized psychosis clinic of the Academic Medical Centre in Amsterdam are also assessed with the CAARMS. The primary outcome is the transition rate to psychosis according to the CAARMS-criteria. Group differences will be analysed with chi-square tests and survival analyses.

Discussion

CBT is a highly tolerated treatment. The psycho-educational CBT approach may prove to be a successful strategy since most people with an At Risk Mental State (ARMS) are distressed by odd disturbing experiences. Giving explanations for and normalising these experiences may reduce the arousal (distress) and therefore may prevent people from developing a catastrophic delusional explanation for their odd experiences and thus prevent them from developing psychosis.

Screening the entire help-seeking population referred to community mental health services with a two-stage strategy, as compared with traditional referral to a specialist clinical psychosis centre, might detect more ultra-high-risk (UHR) patients. This type of screening could be implemented in mental health care as routine screening. The trial is registered at Current Controlled trials as trial number ISRCTN21353122.

Are psychotic experiences among detained juvenile offenders explained by trauma and substance use?

OBJECTIVE

High rates of psychotic experiences among detained adolescents have been reported. However, the significance of psychotic experiences in detained juveniles is still poorly understood. The current study, therefore, (1) examines whether psychotic experiences could be explained by substance use and/or traumatic experiences, and (2) investigates this objective without taking into account the frequently occurring paranoia-related symptoms that may not be psychosis-related in detained minors.

METHOD

Data were derived from 231 detained adolescents. By means of the Diagnostic Interview Schedule for Children, psychotic experiences, life-threatening events and substance use were assessed while the Child Traumatic Questionnaire was used for a history of abuse and neglect.

RESULTS

In univariate logistic regression analyses, having psychotic experiences was positively associated with substance-related (e.g. past year intense marihuana use) and trauma-related (e.g. emotional abuse) variables. However, without taken paranoia-related experiences into account, different associations between psychotic experiences and substance-related and/or trauma-related variables were found. After building best fitting models, logistic regression analyses demonstrated a preponderance of trauma-related over substance-related variables in predicting the number of psychotic experiences (i.e. 0, 1-2, >2).

CONCLUSION

These findings suggest that psychotic experiences in detained adolescents may be explained by trauma and substance use. In addition, paranoia-related experiences seemed to be particularly associated with emotional abuse.

Psychosis risk for parents and siblings of Dutch and Moroccan-Dutch patients with non-affective psychotic disorder

BACKGROUND

Studies in the UK compared psychosis risks for first-degree relatives of White and African-Caribbean patients and found "normal" risks for the parents of Caribbean patients, but very high risks for siblings of second-generation Caribbean patients.

AIM

To compare the risk of non-affective psychotic disorder (NAPD) for the parents and siblings of Moroccan-Dutch patients to that for the parents and siblings of Dutch patients. The "Moroccan-Dutch" are Dutch residents of Moroccan origin (first or second generation).

METHOD

Informants related to 29 Moroccan-Dutch and 63 Dutch patients were interviewed about the presence of psychiatric disorders in first-degree relatives (N=508), by means of the Family Interview for Genetic Studies.

RESULTS

The risks for NAPD in both parent groups were similar (age and sex-adjusted odds ratio 1.0; 95% CI: 0.3-3.8). However, among the siblings, the risk for NAPD was significantly higher for the Moroccan-Dutch than for the Dutch (sex-adjusted hazard ratio 4.5; 95% Confidence Interval: 1.5-14.0). This was due to a large number of cases among the brothers of the Moroccan-Dutch patients (N=14), not among their sisters (N=1). Owing to small numbers separate hazard ratios for the first and the second generation were not calculated.

CONCLUSION

These preliminary results suggest that environmental factors in the Netherlands have a great impact on the psychosis risk for male immigrants from Morocco.