Putative psychotic symptoms in the Mexican American population: prevalence and co-occurrence with psychiatric disorders

Ethnoracial Risk Variation Across the Psychosis Continuum in the US: A Systematic Review and Meta-Analysis

Importance

Studies suggest a higher risk of schizophrenia diagnoses in Black vs White Americans, yet a systematic investigation of disparities that include other ethnoracial groups and multiple outcomes on the psychosis continuum is lacking.

Objective

To identify ethnoracial risk variation in the US across 3 psychosis continuum outcomes (ie, schizophrenia and other psychotic disorders, clinical high risk for psychosis [CHR-P], and psychotic symptoms [PSs] and psychotic experiences [PEs]).

Data Sources

PubMed, PsycINFO and Embase were searched up to December 2022.

Study Selection

Observational studies on ethnoracial differences in risk of 3 psychosis outcomes.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Using a random-effects model, estimates for ethnoracial differences in schizophrenia and PSs/PEs were pooled and moderation by sampling and setting was determined, along with the assessment of heterogeneity and risk of bias.

Main Outcomes and Measures

Risk of schizophrenia and other psychotic disorder, CHR-P, and conversion to psychosis among CHR-P and PSs/PEs.

Results

Of 64 studies in the systematic review, 47 were included in the meta-analysis comprising 54 929 people with schizophrenia and 223 097 with data on PSs/PEs. Compared with White individuals, Black individuals had increased risk of schizophrenia (pooled odds ratio [OR], 2.07; 95% CI, 1.64-2.61) and PSs/PEs (pooled standardized mean difference [SMD], 0.10; 95% CI, 0.03-0.16), Latinx individuals had higher risk of PSs/PEs (pooled SMD, 0.15; 95% CI, 0.08-0.22), and individuals classified as other ethnoracial group were at significantly higher risk of schizophrenia than White individuals (pooled OR, 1.81; 95% CI, 1.31-2.50). The results regarding CHR-P studies were mixed and inconsistent. Sensitivity analyses showed elevated odds of schizophrenia in Asian individuals in inpatient settings (pooled OR, 1.84; 95% CI, 1.19-2.84) and increased risk of PEs among Asian compared with White individuals, specifically in college samples (pooled SMD, 0.16; 95% CI, 0.02-0.29). Heterogeneity across studies was high, and there was substantial risk of bias in most studies.

Conclusions and Relevance

Findings of this systematic review and meta-analysis revealed widespread ethnoracial risk variation across multiple psychosis outcomes. In addition to diagnostic, measurement, and hospital bias, systemic influences such as structural racism should be considered as drivers of ethnoracial disparities in outcomes across the psychosis continuum in the US.

Global prevalence of anxiety and PTSD in immigrants: a systematic review and meta-analysis

BACKGROUND

A systematic and meta-analysis of the prevalence of anxiety and posttraumatic stress disorder (PTSD) in immigrants was conducted.

METHODS

Based on the keywords, scientific databases were systematically searched to identify articles. The search included the three databases PubMed, Google Scholar and Research Gate until June 2020. The analysis was performed to assess the prevalence of anxiety and PTSD; subgroups were examined based on anxiety disorders.

RESULTS

The prevalence of agoraphobia, PTSD, generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), social phobia and specific phobia were 4, 25, 9, 4, 3, 5 and 8%, respectively.

CONCLUSIONS

Considering the findings of the present study regarding the significant prevalence of anxiety and PTSD in the immigrant population, it is necessary to pay special attention to the mental health of this population.

Social Support Networks and Foreign-Birth Status Associated With Obesity, Hypertension and Diabetes Prevalence Among 21-30 and 50-70 Year Old Adults Living in the San Francisco Bay Area

PURPOSE

To examine whether social network characteristics of US-and foreign-born individuals are related to hypertension, diabetes and obesity prevalence.

DESIGN

Cross-sectional.

SETTING

Six San Francisco Bay Area counties.

PARTICIPANTS

N = 1153 cohorts of young and older adults (21-30 and 50-70 years).

MEASURES

Network structure and support measures were calculated using name elicitation and interpreter questions common in egocentric surveys. Hypertension and diabetes were self-reported, and overweight/obesity was determined using body mass index calculations. Foreign-birth status was based on country of birth.

ANALYSIS

Adjusted and unadjusted logistic regression models were used to examine associations between network characteristics and hypertension, diabetes and overweight/obesity. These relationships were tested for moderation by foreign-birth status, age and gender.

RESULTS

Higher percentages of family members (AOR = 4.16, CI: 1.61-10.76) and same-sex individuals (AOR = 3.41, CI: 1.25-9.35) in the composition of respondents' networks were associated with overweight/obesity. Higher composition of family members (AOR = 3.54, CI: 1.09-11.48) was associated with hypertension. Respondents whose networks composed of higher numbers of advice individuals (AOR = 0.88, CI: 0.77-0.99), female respondents (AOR = 0.52, CI: 0.35-0.77) and foreign-born respondents (AOR = 0.54, CI: 0.32-0.92) were less likely to report overweight/obesity. Diabetes was associated with higher composition of individuals living within 5-minutes to respondents (AOR = 5.13, CI: 1.04-25.21).

CONCLUSION

Family and network support members such as advice individuals could be potential targets for chronic disease prevention, particularly among older adults and immigrants.

Ethnic differences in the diagnosis of schizophrenia and mood disorders during admission to an academic safety-net psychiatric hospital

U.S. Hispanics, now the single largest minority group in the country, face unique mental health disparities. The current study utilizes Andersen's Behavioral Model of Health Service Use to examine ethnic disparities in receiving a schizophrenia or mood disorder diagnosis at psychiatric hospital admission. Our retrospective cohort study examined electronic health record data at an academic safety-net psychiatric hospital for adult patients (n = 5571) admitted between 2010 and 2013. Logistic regression with block-wise entry of predisposing, enabling and need variables was used to examine ethnic disparities in receiving a schizophrenia diagnosis at admission. The block of need factors was the strongest predictor of receiving a schizophrenia diagnosis compared to predisposing and enabling factors. Compared to non-Hispanic whites, Hispanics and African Americans had a greater likelihood of receiving a schizophrenia diagnosis at admission. Additionally, patients diagnosed with schizophrenia had elevated positive and negative symptoms and were more likely to be male, single/unmarried, homeless, high inpatient service utilizers, involuntarily hospitalized, and to exhibit functional impairment at psychiatric hospital admission. To address elevated positive and negative symptoms of schizophrenia, functional impairment, social withdrawal, and high inpatient service utilization, promising psychosocial interventions should be adapted for racial and ethnic minority populations and utilized as an adjuvant to antipsychotic medication.

A latent class analysis of psychotic symptoms in the general population

OBJECTIVE

Individuals with psychotic symptoms may actually correspond to various subgroups, characterized by different patterns of psychotic symptoms as well as specific sociodemographic and clinical correlates. We aimed to identify groups of individuals from the general population with specific patterns of psychotic symptoms.

METHODS

In a 38,694-subject survey, a latent class analysis was performed to identify subgroups based on the distribution of seven psychotic symptoms taken from the Mini International Neuropsychiatric Interview. The different classes were subsequently compared according to sociodemographic and clinical correlates.

RESULTS

The best fit was obtained with a four-class solution, including the following: (1) a class with a low prevalence of all psychotic symptoms ('LOW', 85.9%); (2) a class with a high prevalence of all psychotic symptoms ('HAL + DEL', 1.7%); and classes with a high prevalence of (3) hallucinations ('HAL', 4.5%) or (4) delusions ('DEL', 7.9%). The HAL + DEL class displayed higher rates of history of trauma, social deprivation and migrant status, while the HAL and DEL classes displayed intermediate rates between HAL + DEL and LOW. HAL + DEL displayed the highest rates of psychotic and non-psychotic disorders and the use of mental health treatment, while HAL and DEL displayed intermediate rates of these disorders between HAL + DEL and LOW. In comparison to the HAL class, psychotic and substance use disorders were more frequent in the DEL class, while anxiety and mood disorders were less frequent.

CONCLUSION

These findings support the hypothesis of a continuum model relating the level of psychotic symptoms to the level of global psychopathology.

Culture in la clínica: Evaluating the utility of the Cultural Formulation Interview (CFI) in a Mexican outpatient setting

While the classification of psychiatric disorders has been critiqued for failing to adequately account for culture, the inclusion of the Cultural Formulation Interview (CFI) in the DSM-5 has been viewed as a promising development for the inclusion of cultural factors in diagnosis and treatment of mental illness. In this study, we assess the appropriateness, acceptability, and clinical utility of the CFI among outpatients in a Mexican psychiatric hospital. Our assessment included observations of psychiatric residents' application of the CFI with 19 patients during routine outpatient visits, along with pre- and post-CFI interviews to determine providers' and patients' views of the CFI. The CFI was generally well received by providers and patients, viewed as a way of building trust and increasing providers' understanding of contextual factors influencing mental illness, such as social support. However, the CFI questions specifically related to "culture" were of limited effect and both patients and providers did not view them as useful. We discuss implications for the clinical assessment of cultural factors influencing mental health and illness and for the incorporation of the CFI in Mexican clinical settings.

Hispanic immigrants in the USA: social and mental health perspectives

Hispanic immigration in the USA and its effect on many areas of US society are of great relevance to health care, public health, mental health, and medical and social sciences. In this report, we review and discuss pertinent literature on causes, procedures, and eventual outcomes of Hispanic migration waves throughout the last four decades. Hispanic immigrants do not constitute a monolithic group, despite the clear predominance of Mexican and Mexican-American segments. Common features of Hispanic immigrants include a younger average age, higher presence of married households, and lower educational levels than the overall US population. Differences within the Hispanic immigrant population are present in naturalisation figures, English language fluency, occupational and income status, health insurance coverage, and sense of accomplishment in the host society. We examine most of these aspects in the context of the so-called Hispanic paradox, presented as both a cause and a result of a heavily discussed acculturative process. We investigate prevalence and other data on depression, anxiety, substance abuse, and psychotic syndromes, with emphasis on the need to do further neurobiological, epigenetic, and sociocultural research in the Hispanic population.

Correlates in the Endorsement of Psychotic Symptoms and Services Use: Findings from the Collaborative Psychiatric Epidemiology Surveys

Endorsement of psychotic symptoms serves as an indicator of significant health issues and interpersonal distress. Seeking services is the ultimate recourse for many individuals, yet few studies have assessed the help-seeking process in a nationally representative sample. This study, guided by Lewis-Fernández et al.'s (J Nerv Ment Dis 197(5):337-347, 2009) analyses, examined the association of lifetime endorsement of psychotic symptoms with demographic, clinical and support system variables and types of services received. Based on nationally weighted epidemiological data, 11.6 % of adults reported one or more psychotic symptoms. Psychotic symptoms were associated with poor physical and mental health, specifically depressive, anxiety, and substance use disorders. Respondents were more likely to receive services from both informal and mental health providers and were more likely to be hospitalized than those not endorsing psychotic symptoms. Study findings inform community efforts to develop comprehensive services for individuals experiencing psychotic symptoms.

Effects of a culturally sensitive assessment on symptom profiles in native Dutch and Moroccan patients with a first psychosis referral

Previous studies have reported a higher incidence of psychosis in Moroccan immigrants in the Netherlands than among native-born residents. However, this disparity was substantially attenuated when cultural differences in symptom presentation were taken into account. To better understand the impact of different diagnostic procedures on incidence rates, we examined the effects of the use of a culturally sensitive diagnostic interview, compared to a standard semi-structured diagnostic interview, on symptom profiles among Moroccan immigrant and native Dutch patients in the Netherlands. A total of 26 Dutch and 26 Moroccan patients referred with a possible first psychosis diagnosis were interviewed twice: once with the standard version and once with a culturally adapted version of the Comprehensive Assessment of Symptoms and History questionnaire (CASH and CASH-CS, respectively). Among native Dutch patients, symptoms profiles based on CASH and CASH-CS interviews were very similar. By contrast, among Moroccan immigrant patients, symptom profiles based on CASH and CASH-CS interviews differed substantially, with more mania symptoms (+30%; p < .05) and fewer delusions (-31%; p < .05) reported when using the CASH-CS. These results suggest that the over-diagnosis of schizophrenia in Moroccan immigrants with a first psychosis referral may be related to a tendency to under-detect mood symptoms and over-detect positive psychotic symptoms when a standard diagnostic procedure is used. This bias may be corrected, at least in part, by the use of a culturally sensitive interview instrument such as the CASH- CS.

Racial-ethnic disparities in empirically-derived subtypes of subclinical psychosis among a U.S. sample of youths

INTRODUCTION

Racial-ethnic minority status is a consistent risk factor for schizophrenia, with associations extending to bipolar disorder and subthreshold psychotic experiences. However, few epidemiologic studies have been conducted in the U.S., and evidence is inconsistent. Furthermore, no U.S. studies of youths have directly investigated the phenomenological overlap between schizophrenia and bipolar disorder. We aimed to do so at the subthreshold level in the Philadelphia Neurodevelopmental Cohort.

METHODS

Participants included 6533 individuals, age 11-21years, from a community healthcare network. Latent class analysis was used to form subtypes of sub-psychosis based on 12 attenuated positive items and 7 mania items without duration criteria. Associations between race-ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, "other") and sub-psychosis subtype were estimated using latent class regression.

RESULTS

Four classes were identified: Sub-positive Only (13.4%), Mania Only (15.5%), Both (9.1%), and Neither (62.0%). Minority participants were generally more likely than non-Hispanic whites to belong to one of the three sub-psychosis classes compared to the Neither class. Associations for Hispanics and non-Hispanic blacks remained after adjustment for age, sex, and maternal education, and restriction to participants without significant physical health conditions. Racial-ethnic disparities were greater in magnitude for the two classes characterized by sub-positive symptoms, Sub-positive Only and Both, than for the Mania Only class. This pattern was statistically significant among non-Hispanic blacks.

CONCLUSIONS

We found evidence for racial-ethnic disparities in empirically-derived subtypes of subthreshold psychosis, broadly defined, among U.S. youths. Further research is needed to determine whether these disparities persist to the clinical disorder level in adulthood.

Negative symptoms and impaired social functioning predict later psychosis in Latino youth at clinical high risk in the North American prodromal longitudinal studies consortium

AIM

Examining ethnically related variables in evaluating those at risk for psychosis is critical. This study investigated sociodemographic and clinical characteristics of Latino versus non-Latino clinical high-risk (CHR) subjects and healthy control (HC) subjects in the first North American Prodrome Longitudinal Study.

METHODS

Fifty-six Latino CHR subjects were compared to 25 Latino HC and 423 non-Latino CHR subjects across clinical and demographic variables. Thirty-nine of the 56 CHR subjects completed at least one subsequent clinical evaluation over the 2.5-year period with 39% developing a psychotic illness. Characteristics of Latino CHR subjects who later converted to psychosis ('converters') were compared to those who did not ('non-converters').

RESULTS

Latino CHR subjects were younger than non-Latino CHR subjects and had less education than Latino HC subjects and non-Latino CHR counterparts. Latino CHR converters had higher scores than Latino non-converters on the Structured Interview for Prodromal Syndromes total negative symptoms that were accounted for by decreased expression of emotion and personal hygiene/social attentiveness subsections. Latino CHR converters scored lower on the global functioning:social scale, indicating worse social functioning than Latino non-converters.

CONCLUSION

Based on this sample, Latino CHR subjects may seek treatment earlier and have less education than non-Latino CHR subjects. Deficits in social functioning and impaired personal hygiene/social attentiveness among Latino CHR subjects predicted later psychosis and may represent important areas for future study. Larger sample sizes are needed to more thoroughly investigate the observed ethnic differences and risk factors for psychosis in Latino youth.

Immigration and psychotic experiences in the United States: Another example of the epidemiological paradox?

In Europe, it is widely established that immigration increases risk for psychotic disorder. However, research has yet to confirm this association in the United States, where immigrants paradoxically report better health status than their native-born counterparts. Further, few studies have examined this topic with respect to sub-threshold psychotic experiences, which are more common than psychotic disorders in the general population. This study analyzes the (1) National Comorbidity Survey-Replication, (2) the National Latino and Asian American Survey, and (3) the National Survey of American Life, in order to determine whether generation status had any impact on risk for lifetime and 12-month PE, and whether these associations vary across racial/ethnic groups, adjusting for demographic variables and socioeconomic status. We found an absence of an immigration effect on PE across various ethnic groups and across various geographic areas, and found that immigration is actually protective among Latinos, supporting the idea that the epidemiological paradox extends to the psychosis phenotype.

Clinical Encounters with Immigrants: What Matters for U.S. Psychiatrists

About 3.2 percent of the population across the globe are migrants. Today, unprecedented numbers of people are relocating in the U.S. and more than ever, psychiatrists find themselves caring for immigrant patients. International migration is a multilayered issue that often has implications for the mental health of migrants. Thus, there is an increasing interest in understanding how the different factors associated with migration processes affect the mental health outcomes of immigrants. We group these factors into three categories: immigrant process, clinical encounter, and mental health services. When possible, we incorporate a gendered and life span perspective and suggest avenues for including what we know into the care of children, adults, and elderly psychiatric patients with immigrant backgrounds. We pay special attention to the immigrant paradox literature, which explains why some immigrants are healthier when they start their journey, and why their mental health deteriorates as they live longer in the host societies. We aim at providing psychiatrists an understanding of what to ask, assess, and consider when caring for patients who are international migrants.

Treatment Outcome in Depressed Latinos Predicted by Concomitant Psychosislike Symptoms

We compared treatment response (≥50 decrease in Nine-Item Patient Health Questionnaire total score) among 24 Latinos with major depressive disorder, presenting with and without specific psychosislike symptoms: A, hearing noises or house sounds, B, hearing voices calling one's name, C, seeing fleeting visions such as shadows, and D, symptoms more likely to be truly psychotic (e.g., poorly defined and short-lasting voices [other than B], fleeting paranoid ideation, or fleeting ideas of reference). 18 subjects (75%) endorsed symptoms of cluster A, 12 (50%) of cluster B, 10 (31%) of cluster C, and 12 (50%) of cluster D. Only subjects who reported symptoms from the D cluster exhibited significantly unfavorable depressive outcomes (compared to those with absence of D symptoms). The authors propose a phenomenological differentiation between benign psychosislike symptoms (clusters A-C) and the expression of the psychotic continuum (cluster D) in depressed Latinos.

Intergenerational transmission of the effects of acculturation on health in Hispanic Americans: a fetal programming perspective

We propose a transdisciplinary, life span framework for examining the underlying cause of the observed intergenerational decline in health among Hispanic Americans. We focus on acculturation, and we posit that acculturation-related processes in first-generation Hispanic immigrant mothers may affect the intrauterine development of an unborn child, via the process of fetal programming, to produce phenotypic effects that may alter the susceptibility for noncommunicable chronic diseases. In this manner, an intergenerational cascade of perpetuation may become established. Our framework may shed light on the biological, behavioral, and social causes of intergenerational cycles of vulnerability among immigrant minority groups, with public health and policy implications for primary prevention and intervention.

Normal or abnormal? 'Normative uncertainty' in psychiatric practice

The 'multicultural clinical interaction' presents itself as a dilemma for the mental health practitioner. Literature describes two problematic areas where this issues emerges--how to make an adequate distinction between religious rituals and the rituals that may be symptomatic of 'obsessive compulsive disorder' (OCD), and how to differentiate 'normative' religious or spiritual beliefs, behaviours, and experiences from 'psychotic' illnesses. When it comes to understanding service user's 'idioms of distress', beliefs about how culture influences behaviour can create considerable confusion and 'normative uncertainty' for mental health practitioners. In the absence of clear diagnostic and assessment criteria on distinguishing between 'culture' and 'psychopathology', practitioners have had to rely on their own intuition and seek out possible 'strategies' or 'procedures' from a contradictory and cross-disciplinary evidence base. Decontextualisation of service users' experiences may result in the pathologisation of culturally 'normative' phenomenon, 'category fallacy' errors, and poor health care experiences and outcomes for service users.This paper situates this dilemma within a wider debate that has concerned both the biomedical and social sciences, namely, the unresolved question of 'normality' or 'abnormality'. Indeed, issues that arise from dilemmas surrounding the question of 'culture' or 'psychopathology' are intimately tied to wider cultural ideas about what is considered 'normal'. The disciplines of psychiatry, psychology, and medical anthropology have struggled to establish workable criteria against which to judge behaviour as 'normal', 'abnormal', or 'pathological'. Three models for understanding mental 'abnormality' are evident in 'transcultural psychiatry' (what is now commonly known as 'cultural psychiatry'), and these models have corresponded closely to the interpretive models used by anthropologists attempting to make sense of the apparent diversity of human societies. The three models of 'absolutism', 'universalism' and 'cultural relativism' have not only important consequences for the nature and conduct of research enquiry, but also have implications for how the dilemma of 'culture' or 'psychopathology' is attended to in clinical practice.

First rank symptoms for schizophrenia

BACKGROUND

Early and accurate diagnosis and treatment of schizophrenia may have long-term advantages for the patient; the longer psychosis goes untreated the more severe the repercussions for relapse and recovery. If the correct diagnosis is not schizophrenia, but another psychotic disorder with some symptoms similar to schizophrenia, appropriate treatment might be delayed, with possible severe repercussions for the person involved and their family. There is widespread uncertainty about the diagnostic accuracy of First Rank Symptoms (FRS); we examined whether they are a useful diagnostic tool to differentiate schizophrenia from other psychotic disorders.

OBJECTIVES

To determine the diagnostic accuracy of one or multiple FRS for diagnosing schizophrenia, verified by clinical history and examination by a qualified professional (e.g. psychiatrists, nurses, social workers), with or without the use of operational criteria and checklists, in people thought to have non-organic psychotic symptoms.

SEARCH METHODS

We conducted searches in MEDLINE, EMBASE, and PsycInfo using OvidSP in April, June, July 2011 and December 2012. We also searched MEDION in December 2013.

SELECTION CRITERIA

We selected studies that consecutively enrolled or randomly selected adults and adolescents with symptoms of psychosis, and assessed the diagnostic accuracy of FRS for schizophrenia compared to history and clinical examination performed by a qualified professional, which may or may not involve the use of symptom checklists or based on operational criteria such as ICD and DSM.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all references for inclusion. Risk of bias in included studies were assessed using the QUADAS-2 instrument. We recorded the number of true positives (TP), true negatives (TN), false positives (FP), and false negatives (FN) for constructing a 2 x 2 table for each study or derived 2 x 2 data from reported summary statistics such as sensitivity, specificity, and/or likelihood ratios.

MAIN RESULTS

We included 21 studies with a total of 6253 participants (5515 were included in the analysis). Studies were conducted from 1974 to 2011, with 80% of the studies conducted in the 1970's, 1980's or 1990's. Most studies did not report study methods sufficiently and many had high applicability concerns. In 20 studies, FRS differentiated schizophrenia from all other diagnoses with a sensitivity of 57% (50.4% to 63.3%), and a specificity of 81.4% (74% to 87.1%) In seven studies, FRS differentiated schizophrenia from non-psychotic mental health disorders with a sensitivity of 61.8% (51.7% to 71%) and a specificity of 94.1% (88% to 97.2%). In sixteen studies, FRS differentiated schizophrenia from other types of psychosis with a sensitivity of 58% (50.3% to 65.3%) and a specificity of 74.7% (65.2% to 82.3%).

AUTHORS' CONCLUSIONS

The synthesis of old studies of limited quality in this review indicates that FRS correctly identifies people with schizophrenia 75% to 95% of the time. The use of FRS to diagnose schizophrenia in triage will incorrectly diagnose around five to 19 people in every 100 who have FRS as having schizophrenia and specialists will not agree with this diagnosis. These people will still merit specialist assessment and help due to the severity of disturbance in their behaviour and mental state. Again, with a sensitivity of FRS of 60%, reliance on FRS to diagnose schizophrenia in triage will not correctly diagnose around 40% of people that specialists will consider to have schizophrenia. Some of these people may experience a delay in getting appropriate treatment. Others, whom specialists will consider to have schizophrenia, could be prematurely discharged from care, if triage relies on the presence of FRS to diagnose schizophrenia. Empathetic, considerate use of FRS as a diagnostic aid - with known limitations - should avoid a good proportion of these errors.We hope that newer tests - to be included in future Cochrane reviews - will show better results. However, symptoms of first rank can still be helpful where newer tests are not available - a situation which applies to the initial screening of most people with suspected schizophrenia. FRS remain a simple, quick and useful clinical indicator for an illness of enormous clinical variability.

Gender differences in alcohol and drug use among Hispanic adults: the influence of family processes and acculturation

We examine the influence of family processes and acculturation for gender differences in alcohol and drug use among a sample representative of the Hispanic population in Miami-Dade County, Florida (N = 734). We found that (a) increases in age at marriage and acculturation were associated with greater substance use, (b) the associations between age at marriage, acculturation, and substance use were found to be greater for Hispanic women than men, and (c) with each additional child born, Hispanic women are increasingly less likely to use substances than Hispanic men. Data reveal that family processes and acculturation jointly impact substance use.

An exploration of how psychotic-like symptoms are experienced, endorsed, and understood from the National Latino and Asian American Study and National Survey of American Life

OBJECTIVE

. To examine racial-ethnic differences in the endorsement and attribution of psychotic-like symptoms in a nationally representative sample of African-Americans, Asians, Caribbean Blacks, and Latinos living in the USA.

DESIGN

Data were drawn from a total of 979 respondents who endorsed psychotic-like symptoms as part of the National Latino and Asian American Study (NLAAS) and the National Survey of American Life (NSAL). We use a mixed qualitative and quantitative analytical approach to examine sociodemographic and ethnic variations in the prevalence and attributions of hallucinations and other psychotic-like symptoms in the NLAAS and NSAL. The lifetime presence of psychotic-like symptoms was assessed using the World Health Organization Composite International Diagnostic Interview (WMH-CIDI) psychotic symptom screener. We used logistic regression models to examine the probability of endorsing the four most frequently occurring thematic categories for psychotic-like experiences by race/ethnicity (n > 100). We used qualitative methods to explore common themes from participant responses to open ended questions on their attributions for psychotic-like symptoms.

RESULTS

African-Americans were significantly less likely to endorse visual hallucinations compared to Caribbean Blacks (73.7% and 89.3%, p < .001), but they endorsed auditory hallucinations symptoms more than Caribbean Blacks (43.1% and 25.7, p < .05). Endorsing delusions of reference and thought insertion/withdrawal were more prevalent for Latinos than for African-Americans (11% and 4.7%, p < .05; 6.3% and 2.7%, p < .05, respectively). Attribution themes included: supernatural, ghosts/unidentified beings, death and dying, spirituality or religiosity, premonitions, familial and other. Respondents differed by race/ethnicity in the attributions given to psychotic like symptoms.

CONCLUSION

Findings suggest that variations exist by race/ethnicity in both psychotic-like symptom endorsement and in self-reported attributions/understandings for these symptoms on a psychosis screening instrument. Ethnic/racial differences could result from culturally sanctioned beliefs and idioms of distress that deserve more attention in conducting culturally informed and responsive screening, assessment and treatment.

Acculturation-Related Stress and Mental Health Outcomes Among Three Generations of Hispanic Adolescents

Stress associated with acculturation and minority status among Hispanic youth is understudied. Using survey data from the Hispanic Stress Inventory–Adolescent Version (HSI-A), we examined psychosocial stress across eight domains including family economic stress and acculturation-gap stress in a national sample of three generations (first, second, and third or higher) of Hispanic adolescents ( N = 1,263). Research questions addressed generation differences in frequency of stressor events (i.e., discrimination), appraisal of these events, and mental health symptoms. Results indicated that experiences of different categories of stress were significantly related to generation status. The first generation reported more stressors and greater stress appraisal than the third-generation adolescents. Similar levels of discrimination stress were reported by participants regardless of generation. The second-generation participants reported a greater number of Acculturation Gap Stressors than the third generation, and more delinquent and aggressor behaviors than first-generation participants. An acculturation paradox was found with greater stress exposure and stress appraisals in the first-generation youth, but with lower mental health symptoms than later generations. Family integrity and more traditional family values may buffer the negative impact of greater stressor exposure among immigrants and second-generation youth when compared with third-generation adolescents.

Differential impact of isolated psychotic symptoms on treatment outcome of major depressive disorder in the STAR*D cohort of Whites, Blacks and Latinos

OBJECTIVE

To determine whether isolated psychotic symptoms are more likely to be endorsed by depressed Latinos as opposed to other ethnic-racial groups; whether these symptoms affect Latinos similarly to other ethnic-racial groups in terms of treatment response; and whether they are more likely to be associated with anxiety disorders in depressed Latinos.

METHODS

We analyzed data from STAR*D subjects who self identified as White, Black, or Latino. Rates of isolated psychotic symptoms were assessed by the self-rated Psychiatric Diagnostic Screening Questionnaire (PDSQ) and compared between ethnic-racial groups. Depressive remission outcomes were compared within each ethnic-racial group between subjects who endorsed psychotic symptoms versus no psychotic symptoms. Associations between isolated psychotic symptoms and anxiety disorders were also examined.

RESULTS

Among 2597 eligible subjects with at least one post-baseline assessment and available PDSQ data excluding first-rank symptoms, the prevalence of auditory-visual hallucination was 2.5% in Whites (n=49/1928), 11.3% in Blacks (n=45/398) 6.3% in Latinos (n=17/270) (χ(2)=64.9; df=2; p<0.001). Prevalence of paranoid ideation was 15.5% in Whites (n=299/1927), 31.5% in Blacks (n=126/400), and 21.1% in Latinos (n=57/270) (χ(2)=57.3; df=2; p<0.001). Among Whites and Blacks but not Latinos, depressive remission rates were worse in subjects with auditory-visual hallucinations compared to those without them. Paranoid ideation had a significant negative impact on remission in Whites only. In all ethnic-racial groups, a significant association was found between auditory-visual hallucinations and PTSD and panic disorder.

LIMITATIONS

The STAR*D study did not include any structured clinician-based assessment of psychotic symptoms.

CONCLUSION

Latinos do not appear to have worse outcomes when treated for MDD with auditory-visual hallucinations, differently from Whites and Blacks.

An updated and conservative systematic review and meta-analysis of epidemiological evidence on psychotic experiences in children and adults: on the pathway from proneness to persistence to dimensional expression across mental disorders

BACKGROUND

The psychosis-proneness-persistence-impairment model of psychotic disorder incorporates notions of both phenomenological and temporal continuity (persistence) of psychotic experiences (PE), but not structural continuity. Specific testable propositions of phenomenological continuity and persistence are identified. Method Propositions are tested by systematic reviews of the epidemiology of PE, persistence of PE and disorder outcomes, and meta-analyses (including Monte Carlo permutation sampling, MCPS) of reported rates and odds ratios (ORs).

RESULTS

Estimates of the incidence and prevalence of PE obtained from 61 cohorts revealed a median annual incidence of 2.5% and a prevalence of 7.2%. Meta-analysis of risk factors identified age, minority or migrant status, income, education, employment, marital status, alcohol use, cannabis use, stress, urbanicity and family history of mental illness as important predictors of PE. The mode of assessment accounted for significant variance in the observed rates. Across cohorts, the probability of persistence was very strongly related to the rate of PE at baseline. Of those who report PE, ∼20% go on to experience persistent PE whereas for ∼80%, PE remit over time. Of those with baseline PE, 7.4% develop a psychotic disorder outcome.

CONCLUSIONS

Compelling support is found for the phenomenological and temporal continuity between PE and psychotic disorder and for the fundamental proposition that this relationship is probabilistic. However, imprecision in epidemiological research design, measurement limitations and the epiphenomenological nature of PE invite further robust scrutiny of the continuity theory.

Differential diagnosis between non-pathological psychotic and spiritual experiences and mental disorders: a contribution from Latin American studies to the ICD-11

OBJECTIVE

To review research articles in psychiatry and psychology involving Latin American populations and/or produced by Latin American scholars to investigate the differential diagnosis between spiritual/anomalous experiences and mental disorders in order to contribute to the validity of the International Classification of Diseases towards its 11th edition in this area.

METHOD

We searched electronic databases (PubMed, PsycINFO, Scopus, and SciELO) using relevant keywords (possession, trance, religious experience, spiritual experience, latin, Brazil) for articles with original psychiatric and psychological data on spiritual experiences. We also analyzed the references of the articles found and contacted authors for additional references and data.

RESULTS

There is strong evidence that psychotic and anomalous experiences are frequent in the general population and that most of them are not related to psychotic disorders. Often, spiritual experiences involve non-pathological dissociative and psychotic experiences. Although spiritual experiences are not usually related to mental disorders, they may cause transient distress and are commonly reported by psychotic patients.

CONCLUSION

We propose some features that suggest the non-pathological nature of a spiritual experience: lack of suffering, lack of social or functional impairment, compatibility with the patient's cultural background and recognition by others, absence of psychiatric comorbidities, control over the experience, and personal growth over time.

Predictive validity of a culturally informed diagnosis of schizophrenia: a 30 month follow-up study with first episode psychosis

Previous research has shown discrepancies between a standard diagnostic interview for schizophrenia (CASH) and a culture sensitive version of this instrument (CASH-CS) in Moroccan patients. More specifically we showed that among Moroccan immigrants the CASH-CS resulted in fewer patients with a diagnosis of schizophrenia compared with diagnoses based on the CASH, whereas for Native Dutch patients there was no difference between the CASH and the CASH-CS. The aim of the current study was to compare the predictive validity of a diagnosis of schizophrenia according to the CASH and CASH-CS.

METHOD

Thirty months after referral, 26 Moroccan and 26 native Dutch patients with a suspected first psychotic episode were compared with regard to 30-month diagnostic stability, symptom development, psychosocial functioning, medication use and hospitalization using baseline diagnoses based on the two versions of the CASH.

RESULTS

Moroccan patients who were diagnosed with schizophrenia using the standard CASH at baseline had a significantly better 30-month prognosis than native Dutch patients with the same CASH diagnosis. Prognosis of schizophrenia according to the CASH-CS was similar for Moroccans and native Dutch patients. Diagnostic stability according to the CASH was high for native Dutch (92%), but low for Moroccan patients (27%), whereas diagnostic stability according to the CASH-CS was high for both groups (85% and 81%, respectively).

CONCLUSION

These data raise questions regarding the validity of the standard CASH in Moroccan immigrants in The Netherlands and support the validity of the CASH-CS. As a consequence, there are serious doubts about the validity of previous studies showing an increased incidence of schizophrenia in immigrants using standard diagnostic procedures.

The psychosis continuum in the general population: findings from the São Paulo Epidemiologic Catchment Area Study

The aim of the study was to examine the psychosis continuum in a Latin-American community setting. Data were from the Brazilian São Paulo Epidemiologic Catchment Area Study, a cross-sectional survey conducted in two boroughs of the city of São Paulo. The Composite International Diagnosis Interview (version 1.1) was applied to a probabilistic sample of 1,464 adults, who were interviewed in their household, in order to identify the presence of psychotic symptoms. A subsample was assessed with Schedules for Clinical Assessment in Neuropsychiatry interview. We described the occurrence of psychotic symptoms, categorized into subgroups according to their clinical impact, disability, and help-seeking behavior. The correlation of socio-demographic variables, depressive symptoms, and alcohol and substance use disorders with those psychotic subgroups was analyzed. Polychotomic logistic regression tested the associations between subgroups of psychosis (clinical and subclinical) and the correlates. Of the total sample, 38.0% presented at least one lifetime psychotic symptom, 1.9% met the criteria for an ICD-10 diagnosis of non-affective psychosis, 5.4% presented clinically relevant psychotic symptoms, and 30.7% endorsed clinically non-relevant symptoms. The most common psychotic symptom was delusion with a plausible explanation (in 18.6%). The presence of any psychiatric diagnosis was associated with the presence of psychotic symptoms (OR range, 1.9-8.9). Subclinical psychosis subgroups were found to be associated with the 18-24 year age bracket, chronic depressive mood, and alcohol use disorder. Our results support the concept of a psychosis continuum in Latin-American populations, suggesting that different risk factors influence their manifestation across the continuum.

Substance use disorder comorbidity with schizophrenia in families of Mexican and Central American ancestry

OBJECTIVES

The aims of this study were to estimate the frequency and course of substances use disorders in Latino patients with schizophrenia and to ascertain risk factors associated with substance use disorders in this population.

METHOD

We studied 518 subjects with schizophrenia recruited for a genetic study from the Southwest United States, Mexico, and Central America (Costa Rica and Guatemala). Subjects were assessed using structured interviews and a best estimate consensus process. Logistic regression, chi(2), t test, Fisher's exact test, and Yates' correction, as appropriate, were performed to assess the sociodemographic variables associated with dual diagnosis. We defined substance use disorder as either alcohol or substance abuse or dependence.

RESULTS

Out of 518 patients with schizophrenia, 121 (23.4%) had substance use disorders. Comorbid substance use disorders were associated with male gender, residence in the United States, immigration of Mexican men to the United States, history of depressive syndrome or episode, and being unemployed. The most frequent substance use disorder was alcohol abuse/dependence, followed by marijuana abuse/dependence, and solvent abuse/dependence.

CONCLUSION

This study provides data suggesting that depressive episode or syndrome, unemployment, male gender, and immigration of Mexican men to the United States were factors associated with substance use disorder comorbidity in schizophrenia. Binary logistic regression showed that country of residence was associated with substance use disorder in schizophrenic patients. The percentage of subjects with comorbid substance use disorders was higher in the Latinos living in the United States compared with subjects living in Central America and Mexico.

First contact incidence of psychotic disorders among native Dutch and Moroccan immigrants in the Netherlands: influence of diagnostic bias

BACKGROUND

Several studies have reported increased incidence rates of psychotic disorders among immigrant groups. Surprisingly, the cross-cultural validity of the diagnostic instruments that were used was never tested.

AIMS

To examine whether the incidence rates of psychotic disorders including schizophrenia among Moroccan immigrants to the Netherlands remain increased when a cultural sensitive diagnostic interview is used.

METHOD

We compared first contact incidence with a standard and a cultural sensitive version of a diagnostic interview.

RESULTS

Age and gender adjusted relative risk for psychotic disorders and schizophrenia among Moroccans compared to native Dutch was 7.9 (95% CI 4.7-13.5) and 7.8 (95% CI 4.0-15.2) respectively based on the standard diagnostic interview and 4.2 (95% CI 2.3-7.9) and 1.5 (0.5-4.3) respectively based on the cultural sensitive version the diagnostic interview.

CONCLUSION

First contact incidence of schizophrenia among Moroccans was no longer significantly higher than among ethnic Dutch people when a cultural sensitive diagnostic procedure was applied.

Ethnic origin and increased risk for schizophrenia in immigrants to countries of recent and longstanding immigration

OBJECTIVES

Compare the risk for schizophrenia in immigrants to countries of recent and longstanding immigration. Compare prevalence and incidence rates in black subjects under different conditions.

METHOD

An electronic literature search was complemented by review articles and cross-references. Studies reporting standard diagnosis and incidence or prevalence rates were included.

RESULTS

Immigrants had an increased risk for schizophrenia in countries of longstanding immigration, but with lower risk ratios than in those of recent immigration. The risk was higher in black immigrants and the black population living in the United States. But incidence and prevalence rates in Africa and the Caribbean were similar to those of international studies.

CONCLUSION

Comparing the most recent generation of immigrants with descendants of previous ones may account for the lower risk ratios observed in countries of longstanding vs. recent immigration. Two neurobiological hypotheses are proposed to explain the epidemiological findings in black populations and in immigrants.

Mental illness, nativity, gender and labor supply

We analyzed the impacts of nativity and mental health (MH) on work by gender for non-elderly adults using the 2002 National Survey on Drug Use and Health. We employed two indicators of MH - the K6 scale of Mental Illness (MI) and an indicator for symptoms of Mania or Delusions (M/D). Instrumental variable (IV) models used measures of social support as instruments for MI. Unadjusted work rates were higher for immigrants (vs US-born adults). Regressions show that MI is associated with lower rates of work among US-born males but not immigrant males and females; M/D is associated lower rates of work among US-born males and females, and among immigrant males. Results did not change using IV models for MI. Most persons with MI work, yet symptom severity reduces labor supply among natives especially. Immigrants' labor supply is less affected by MI.

Significance of endorsement of psychotic symptoms by US Latinos

In US regional studies, Latinos frequently endorse psychotic symptoms associated with impairment and mental health service use, yet do not meet criteria for psychotic disorder. Using a nationally representative Latino sample (N = 2554), we examined the prevalence of psychotic symptoms, their relationship to psychotic disorder, their correlates, and their relationship to mental health outcomes. In this sample, 9.5% (SE = 0.7) endorsed 1 or more lifetime psychotic symptoms, yet 93% of endorsers did not meet Structured Clinical Interview for DSM-IV criteria for psychotic disorders. Endorsement was associated with physical and emotional distress, particularly lifetime anxiety and current substance use disorder. Acculturation to US society and reliance on spiritual/religious help were also associated with psychotic symptom endorsement. These symptoms have substantial clinical significance, being independently associated with suicidal ideation, mental health-related disability, and outpatient mental health service utilization. Endorsed psychotic symptoms in Latinos may constitute a clinically significant marker of general psychiatric vulnerability rather than a sign of psychotic disorder.

A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder

A systematic review of all reported incidence and prevalence studies of population rates of subclinical psychotic experiences reveals a median prevalence rate of around 5% and a median incidence rate of around 3%. A meta-analysis of risk factors reveals associations with developmental stage, child and adult social adversity, psychoactive drug use, and also male sex and migrant status. The small difference between prevalence and incidence rates, together with data from follow-up studies, indicates that approximately 75-90% of developmental psychotic experiences are transitory and disappear over time. There is evidence, however, that transitory developmental expression of psychosis (psychosis proneness) may become abnormally persistent (persistence) and subsequently clinically relevant (impairment), depending on the degree of environmental risk the person is additionally exposed to. The psychosis proneness-persistence-impairment model considers genetic background factors impacting on a broadly distributed and transitory population expression of psychosis during development, poor prognosis of which, in terms of persistence and clinical need, is predicted by environmental exposure interacting with genetic risk.

Ethnicity and variability of psychotic symptoms

This review addresses the influence of ethnicity on the expression of psychotic symptoms and the implications for evaluating and treating patients of diverse backgrounds. Growing clinical and population research from Europe and the United States supports a dimensional interpretation of psychosis, yet the evidence suggests that psychotic symptoms place individuals at higher risk for a range of severe psychiatric conditions and adverse outcomes, such as suicidality. Ethnocultural diversity challenges clinicians to accurately interpret the clinical significance of patients' symptom presentations. Disproportionate psychotic symptoms and higher rates of psychotic disorders have been found in some ethnic groups, particularly among immigrants and their offspring, but profound inconsistencies in these patterns remain. More cultural research on the clinical implications of ethnic variation in psychosis is needed. Developing awareness and requisite skills is a priority for clinicians who evaluate and recommend treatments to ethnically diverse patients.

Migration and schizophrenia

PURPOSE OF REVIEW

An exploration of the evidence that a history of migration is a risk factor for schizophrenia and an evaluation of those studies that seek an explanation for this.

RECENT FINDINGS

A meta-analysis found an increased risk for schizophrenia among first-generation and second-generation migrants and found a particularly high risk for migrants from countries where the majority of the population was Black. The latter finding was confirmed and extended by a large first-contact incidence study in the UK, which found excessive risks for schizophrenia and mania in the African-Caribbean and black-African sections of the population. A very high risk of schizophrenia has also been reported for Moroccan males in the Netherlands. The explanation for these findings is uncertain. Social adversity, racial discrimination, family dysfunction, unemployment and poor housing conditions have been proposed as contributing factors. According to one hypothesis, the chronic experience of social defeat disturbs dopamine function in the brain.

SUMMARY

A personal or family history of migration is a high risk factor for schizophrenia and there is now strong evidence against selective migration as the explanation. There is an increasing interest in the impact of social stressors on brain functioning and on the pathogenesis of schizophrenia.