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Anglin DM, Espinosa A, Addington J, Cadenhead KS, Cannon TD, Cornblatt BA, Keshavan M, Mathalon DH, Perkins DO, Stone W, Tsuang M, Woods SW, Walker E, Bearden CE, Ku BS. Association of Childhood Area-Level Ethnic Density and Psychosis Risk Among Ethnoracial Minoritized Individuals in the US. JAMA Psychiatry 2023; 80:1226-1234. [PMID: 37585191 PMCID: PMC10433142 DOI: 10.1001/jamapsychiatry.2023.2841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/13/2023] [Indexed: 08/17/2023]
Abstract
Importance The protective ethnic density effect hypothesis, which suggests that minoritized individuals who grow up in neighborhoods with a high proportion of ethnoracial minoritized groups are protected from the effects of perceived discrimination, has not been examined among individuals at clinical high risk of psychosis (CHR-P). This level of examination may help identify intervention targets for preventing psychosis among high-risk individuals. Objective To examine the association between area-level ethnic density during childhood, perceived discrimination, and psychosis risk outcomes among ethnoracial minoritized individuals with CHR-P. Design, Setting, and Participants Data were collected as part of the North American Prodrome Longitudinal Study-2 (NAPLS 2) between November 2008 and March 2013. Participants included ethnoracial minoritized youth with CHR-P. Area-level ethnoracial minoritized density pertained to the percent of ethnoracial minoritized individuals within the participant's county during childhood. Generalized mixed-effects models with random intercepts for participants, NAPLS 2 site, and county estimated the associations between area-level ethnic density and the risk of psychosis risk outcomes. Self-reported experience of discrimination was assessed. Mediation analyses computed the indirect association of perceived discrimination in the prospective correlation between ethnic density and psychosis risk outcomes. Analyses took place between December 2021 and June 2023. Main Outcomes and Measures Psychosis risk outcomes included remission, symptomatic, progression, and conversion to psychosis and were assessed throughout 24-month follow-up. Results Of 193 individuals, the mean (SD) age was 17.5 (3.4) years and 113 males (58.5%) were included. Participants self-identified as Asian (29 [15.0%]), Black (57 [29.0%]), Hispanic (any race; 87 [45.0%]), or other (First Nations, Middle Eastern, and interracial individuals; 20 [10.4%]). Greater area-level minoritized density was associated with a lower likelihood of remaining symptomatic (relative risk [RR], 0.54 [95% CI, 0.33-0.89]) and having progressively worsening symptoms (RR, 0.52 [95% CI, 0.32-0.86]) compared with being in remission. More perceived discrimination was associated with a higher risk of staying symptomatic (RR, 1.43 [95% CI, 1.09-1.88]) and progressively worsening (RR, 1.34 [95% CI, 1.02-1.78]) compared with being in remission. Perceived discrimination significantly mediated 21.7% (95% CI, 4.1%-67.0%; P = .02) of the association between area-level minoritized density and the likelihood of being in remission. Conclusions and Relevance This study found that among ethnoracial minority youth with CHR-P, growing up in communities with a greater proportion of ethnically minoritized individuals was associated with remission of psychosis risk symptoms partly through lower levels of perceived discrimination. Understanding how the social environment impacts early psychosis risk may help develop effective interventions to prevent psychosis, especially for vulnerable minoritized youth.
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Affiliation(s)
- Deidre M. Anglin
- Department of Psychology, The City College of New York, City University of New York, New York
- The Graduate Center, City University of New York, New York
| | - Adriana Espinosa
- Department of Psychology, The City College of New York, City University of New York, New York
- The Graduate Center, City University of New York, New York
| | - Jean Addington
- Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Tyrone D. Cannon
- Department of Psychiatry, Yale University, New Haven, Connecticut
- Department of Psychology, Yale University, New Haven, Connecticut
| | - Barbara A. Cornblatt
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, New York
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Matcheri Keshavan
- Department of Psychiatry, Harvard Medical School at Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel H. Mathalon
- Department of Psychiatry, University of California, and San Francisco Veterans Affairs Medical Center, San Francisco
| | - Diana O. Perkins
- Department of Psychiatry, University of North Carolina, Chapel Hill
| | - William Stone
- Department of Psychiatry, Harvard Medical School at Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ming Tsuang
- Department of Psychiatry, University of California, San Diego
| | - Scott W. Woods
- Department of Psychiatry, Yale University, New Haven, Connecticut
| | - Elaine Walker
- Department of Psychology, Emory University, Atlanta, Georgia
| | - Carrie E. Bearden
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, California
- Department of Psychology, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, California
| | - Benson S. Ku
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia
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Ku BS, Addington J, Bearden CE, Cadenhead KS, Cannon TD, Compton MT, Cornblatt BA, Druss BG, Gülöksüz S, Mathalon DH, Perkins DO, Tsuang MT, Walker EF, Woods SW, Carrión RE. Associations Between Childhood Area-Level Social Fragmentation, Maladaptation to School, and Social Functioning Among Healthy Youth and Those at Clinical High Risk for Psychosis. Schizophr Bull 2023; 49:1437-1446. [PMID: 37358832 PMCID: PMC10686327 DOI: 10.1093/schbul/sbad093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
BACKGROUND AND HYPOTHESIS Although studies have identified social fragmentation as an important risk factor for schizophrenia and other psychotic disorders, it is unknown whether it may impact social functioning. This study investigates whether social fragmentation during childhood predicts maladaptation to school as well as social functioning during childhood and adulthood. STUDY DESIGN Data were collected from the North American Prodrome Longitudinal Study. Participants included adults at clinical high risk for psychosis (CHR-P) and healthy comparisons (HC). Maladaptation to school and social functioning during childhood were assessed retrospectively and social functioning in adulthood was assessed at baseline. STUDY RESULTS Greater social fragmentation during childhood was associated with greater maladaptation to school (adjusted β = 0.21; 95% CI: 0.02 to 0.40). Social fragmentation was not associated with social functioning during childhood (unadjusted β = -0.08; 95% CI: -0.31 to 0.15). However, greater social fragmentation during childhood predicted poorer social functioning in adulthood (adjusted β = -0.43; 95% CI: -0.79 to -0.07). Maladaptation to school mediated 15.7% of the association between social fragmentation and social functioning. The association between social fragmentation and social functioning was stronger among adults at CHR-P compared to HC (adjusted β = -0.42; 95% CI: -0.82 to -0.02). CONCLUSIONS This study finds that social fragmentation during childhood is associated with greater maladaptation to school during childhood, which in turn predicts poorer social functioning in adulthood. Further research is needed to disentangle aspects of social fragmentation that may contribute to social deficits, which would have implications for the development of effective interventions at the individual and community levels.
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Affiliation(s)
- Benson S Ku
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Jean Addington
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Carrie E Bearden
- Departments of Psychiatry and Biobehavioral Sciences and Psychology, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
| | | | - Tyrone D Cannon
- Department of Psychiatry, Yale University, New Haven, CT, USA
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Michael T Compton
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and New York State Psychiatric Institute, New York, NY, USA
| | - Barbara A Cornblatt
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Benjamin G Druss
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sinan Gülöksüz
- Department of Psychiatry, Yale University, New Haven, CT, USA
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Daniel H Mathalon
- Department of Psychiatry, University of California, and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Diana O Perkins
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA
| | - Ming T Tsuang
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Elaine F Walker
- Department of Psychology, Emory University, Atlanta, GA, USA
| | - Scott W Woods
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Ricardo E Carrión
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Ku BS, Collins M, Anglin DM, Diomino AM, Addington J, Bearden CE, Cadenhead KS, Cannon TD, Cornblatt BA, Druss BG, Keshavan M, Mathalon DH, Perkins DO, Stone WS, Tsuang MT, Woods SW, Walker EF. Associations between childhood ethnoracial minority density, cortical thickness, and social engagement among minority youth at clinical high-risk for psychosis. Neuropsychopharmacology 2023; 48:1707-1715. [PMID: 37438421 PMCID: PMC10579230 DOI: 10.1038/s41386-023-01649-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/16/2023] [Accepted: 06/29/2023] [Indexed: 07/14/2023]
Abstract
An ethnoracial minority density (EMD) effect in studies of psychotic spectrum disorders has been observed, whereby the risk of psychosis in ethnoracial minority group individuals is inversely related to the proportion of minorities in their area of residence. The authors investigated the relationships among area-level EMD during childhood, cortical thickness (CT), and social engagement (SE) in clinical high risk for psychosis (CHR-P) youth. Data were collected as part of the North American Prodrome Longitudinal Study. Participants included 244 ethnoracial minoritized (predominantly Hispanic, Asian and Black) CHR-P youth and ethnoracial minoritized healthy controls. Among youth at CHR-P (n = 164), lower levels of EMD during childhood were associated with reduced CT in the right fusiform gyrus (adjusted β = 0.54; 95% CI 0.17 to 0.91) and right insula (adjusted β = 0.40; 95% CI 0.05 to 0.74). The associations between EMD and CT were significantly moderated by SE: among youth with lower SE (SE at or below the median, n = 122), lower levels of EMD were significantly associated with reduced right fusiform gyrus CT (adjusted β = 0.72; 95% CI 0.29 to 1.14) and reduced right insula CT (adjusted β = 0.57; 95% CI 0.18 to 0.97). However, among those with greater SE (n = 42), the associations between EMD and right insula and fusiform gyrus CT were not significant. We found evidence that lower levels of ethnic density during childhood were associated with reduced cortical thickness in regional brain regions, but this association may be buffered by greater levels of social engagement.
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Affiliation(s)
- Benson S Ku
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA.
| | - Meghan Collins
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Deidre M Anglin
- Department of Psychology, The City College of New York, City University of New York, New York, NY, USA
- The Graduate Center, City University of New York, New York, NY, USA
| | - Anthony M Diomino
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Jean Addington
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Carrie E Bearden
- Departments of Psychiatry and Biobehavioral Sciences and Psychology, Semel Institute for Neuroscience and Human Behavior, UCLA, Los Angeles, CA, USA
| | - Kristin S Cadenhead
- Department of Psychology, The City College of New York, City University of New York, New York, NY, USA
| | - Tyrone D Cannon
- Department of Psychology, Yale University, New Haven, CT, USA
- Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Barbara A Cornblatt
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA
- Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Benjamin G Druss
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Matcheri Keshavan
- Harvard Medical School, Departments of Psychiatry at Massachusetts Mental Health Center Public Psychiatry Division, Beth Israel Deaconess Medical Center, and Massachusetts General Hospital, Boston, MA, USA
| | - Daniel H Mathalon
- Department of Psychiatry, University of California, and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Diana O Perkins
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC, USA
| | - William S Stone
- Harvard Medical School, Departments of Psychiatry at Massachusetts Mental Health Center Public Psychiatry Division, Beth Israel Deaconess Medical Center, and Massachusetts General Hospital, Boston, MA, USA
| | - Ming T Tsuang
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Scott W Woods
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
| | - Elaine F Walker
- Department of Psychology, Emory University, Atlanta, GA, USA
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DeTore NR, Balogun-Mwangi O, Mueser KT, McGurk SR. Comparison of Black and White participants with severe mental illness in response to cognitive remediation as an augmentation of vocational rehabilitation. Schizophr Res 2023; 253:60-67. [PMID: 34772592 PMCID: PMC9088896 DOI: 10.1016/j.schres.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Despite evidence that cognitive remediation improves cognitive and employment outcomes in persons with severe mental illnesses (SMI), its effects have not been systematically compared between Black and White participants. Considering that Black adults have more negative experiences receiving mental health treatment, providers may have greater difficulty engaging and retaining Black Americans in cognitive remediation. Due to the effects of structural racism on reducing employment opportunities for Black Americans, it is unclear whether Black participants will reap the same benefits of cognitive remediation on work outcomes as White Americans. This paper addressed this question. METHODS A secondary analysis was conducted of five randomized controlled trials comparing cognitive remediation (the Thinking Skills for Work program: TSW) and vocational rehabilitation vs. vocational rehabilitation only in 137 Black and 147 White Americans (64.2% schizophrenia-schizoaffective disorder) who were followed up for two years. RESULTS Comparable proportions of Black and White participants were engaged and retained in TSW (>75%). Participants who received TSW improved significantly more in cognition than those receiving vocational services alone, with no racial differences in benefit. Participants in TSW obtained more work, earned more wages, and worked more weeks than those receiving vocational services alone, with no differences between the races. CONCLUSIONS The findings indicate that Black Americans with SMI receiving vocational services could be successfully engaged in and benefit from cognitive remediation, highlighting the vital role of healthcare service systems in giving credence to structural racism to more effectively mitigate racial disparities in treatment outcomes.
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Affiliation(s)
- N R DeTore
- Massachusetts General Hospital, United States of America; Department of Psychiatry, Harvard Medical School, United States of America
| | | | - K T Mueser
- Center for Psychiatric Rehabilitation, Boston University, United States of America; Department of Occupational Therapy, Boston University, United States of America.
| | - S R McGurk
- Center for Psychiatric Rehabilitation, Boston University, United States of America; Department of Occupational Therapy, Boston University, United States of America
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Rakhshan Rouhakhtar P, Roemer C, Reeves G, Schiffman J. The associations between attenuated psychosis symptoms and functioning in Black and White youth at clinical high-risk for psychosis. Schizophr Res 2023; 253:40-47. [PMID: 34922800 DOI: 10.1016/j.schres.2021.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 11/22/2022]
Abstract
Extensive research has demonstrated racial disparities, particularly among Black individuals, in both presentation and course of psychosis spectrum disorders. Few studies, however, have examined racial differences in the clinical high-risk (CHR) phase of illness. It is unclear if functional deficits seen in association with CHR symptoms generalize to marginalized racial groups, or whether race may play a role in the link between symptoms and functioning. In a sample of youth at CHR (N = 46), the present study examined the effect of race (Black and White represented in this sample) on the relation between CHR symptoms and social/role functioning. Race had a moderating effect on the relation between CHR symptoms and social functioning for total positive symptom score (p < .04, f2 = 0.10). Although positive symptoms were associated with worse social functioning for White participants, no association was found for Black participants. Follow up analyses indicated suspiciousness was a statistically significant predictor of social functioning for White participants but was unrelated to functioning for Black participants. Results may be indicative of phenomenon experienced by individuals within racial minority groups (e.g., "healthy suspiciousness") or potential measurement validity concerns. Findings further the understanding of racial differences in the CHR phase of illness among White and Black youth and highlight limitations of the existing CHR literature and assessment tools for diverse youth.
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Affiliation(s)
- Pamela Rakhshan Rouhakhtar
- University of Maryland, Baltimore County, Department of Psychology, 1000 Hilltop Circle, Baltimore, MD 21250, United States of America; University of Maryland School of Medicine, Division of Child & Adolescent Psychiatry, 701 W. Pratt Street, Baltimore, MD 21201, United States of America.
| | - Caroline Roemer
- University of Maryland, Baltimore County, Department of Psychology, 1000 Hilltop Circle, Baltimore, MD 21250, United States of America
| | - Gloria Reeves
- University of Maryland School of Medicine, Division of Child & Adolescent Psychiatry, 701 W. Pratt Street, Baltimore, MD 21201, United States of America
| | - Jason Schiffman
- University of California, Irvine, Department of Psychological Science, 4201 Social & Behavioral Sciences Gateway, Irvine, CA 92697, United States of America
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Dobbins S, Hubbard E, Leutwyler H. Education Mediates Racial Disparities in Cognitive Impairment Among Older Adults With Schizophrenia. Clin Gerontol 2023; 46:66-79. [PMID: 33579181 PMCID: PMC8610378 DOI: 10.1080/07317115.2021.1882021] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES In the general population, the construct of race is associated with disparities in cognitive aging. There are notable racial group disparities and inequities among people living with schizophrenia (PLWSz). Despite the salience of the construct of race in schizophrenia, there remains a knowledge gap about racial disparities in cognitive impairment among older adults in this vulnerable population. Our study uses mediation analysis to examine racial disparities in cognitive impairment among older adults with schizophrenia. METHODS We assess global cognition in PLWSz over age 55 with the Measurement and Treatment Research to Improve Cognition in Schizophrenia cognitive test battery in our "all-comer" sample (N = 64). The primary exposure is self-reported racial group. We examine mediation of cognitive impairment through educational attainment, adjusting for psychiatric illness severity, history of substance use, and vascular risk factors. RESULTS There was a Black/non-Black group racial disparity in global cognitive score (-2.8, 95% CI: -4.4, -1.3) after adjusting for confounding and interaction. This disparity was significantly mediated by years of education. CONCLUSIONS There are notable racial disparities in cognitive impairment among older adults with schizophrenia; however, differences in cognitive scores between racial groups are mediated by level of education. CLINICAL IMPLICATIONS Social determinants of health, particularly educational attainment, are important risk factors for cognitive impairment in PLWSz and should be considered by clinicians. Early screening and assessment of cognitive symptoms is essential to addressing health disparities/inequalities among older adults living with schizophrenia. ABBREVIATIONS CDE Controlled Direct EffectsHIV: Human Immunodeficiency VirusMATRICS: Measurement and Treatment Research to Improve Cognition in SchizophreniaMCCB: MATRICS Consensus Cognitive BatteryMTE: Marginal Total EffectsNDE: Natural Direct EffectsPANSS: Positive and Negative Symptom ScalePLWSz: People with schizophrenia.
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Affiliation(s)
- Sarah Dobbins
- University of California, San Francisco School of Nursing, 2 Koret Way, San Francisco, CA 94143, USA
| | - Erin Hubbard
- University of California, San Francisco School of Nursing, 2 Koret Way, San Francisco, CA 94143, USA
| | - Heather Leutwyler
- University of California, San Francisco School of Nursing, 2 Koret Way, San Francisco, CA 94143, USA
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Editorial: Precision psychiatry and the clinical care for people with schizophrenia: sex, race and ethnicity in relation to social determinants of mental health. Curr Opin Psychiatry 2022; 35:137-139. [PMID: 35579868 DOI: 10.1097/yco.0000000000000781] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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