Social and spatial heterogeneity in psychosis proneness in a multilevel case-prodrome-control study

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Understanding Associations Between Race/Ethnicity, Experiences of Discrimination, and Psychotic-like Experiences in Middle Childhood

OBJECTIVE

The present study aimed to examine factors that may account for race/ethnicity differences in psychotic-like experiences (PLEs) in a middle childhood sample, including evidence for experiences of discrimination as a psychosocial mediator of these differences.

METHOD

In a sample of 9- to 10-year-olds (N = 10,839) from the Adolescent Brain Cognitive Development Study, we compared PLEs across racial/ethnic groups. We also examined whether experiences of discrimination indirectly linked racial/ethnic identity and PLEs and whether social support moderated this indirect association.

RESULTS

Differences between racial/ethnic groups were found in the endorsement of PLEs, such that Black and Hispanic participants endorsed higher levels of PLEs compared with Asian, multiracial/multiethnic, and White participants. These differences were accounted for in part by experiences of discrimination, an indirect effect that was in turn attenuated by increased social support.

CONCLUSION

This is the first study to suggest that the experience of discrimination may indirectly link the association between racial/ethnic differences and endorsement of PLEs using the Prodromal Questionnaire-Brief Child Version and additionally that social support may act as a moderator of this mediation. Results provide evidence that social inequities such as racial discrimination may contribute to increases in PLEs. These findings shed further light on the links between structural racism and mental health inequities for people in minoritized groups.

Evaluating physical urban features in several mental illnesses using electronic health record data

Objectives

Understanding the potential impact of physical characteristics of the urban environment on clinical outcomes on several mental illnesses.

Materials and Methods

Physical features of the urban environment were examined as predictors for affective and non-affective several mental illnesses (SMI), the number and length of psychiatric hospital admissions, and the number of short and long-acting injectable antipsychotic prescriptions. In addition, the urban features with the greatest weight in the predicted model were determined. The data included 28 urban features and 6 clinical variables obtained from 30,210 people with SMI receiving care from the South London and Maudsley NHS Foundation Trust (SLaM) using the Clinical Record Interactive Search (CRIS) tool. Five machine learning regression models were evaluated for the highest prediction accuracy followed by the Self-Organising Map (SOM) to represent the results visually.

Results

The prevalence of SMI, number and duration of psychiatric hospital admission, and antipsychotic prescribing were greater in urban areas. However, machine learning analysis was unable to accurately predict clinical outcomes using urban environmental data.

Discussion

The urban environment is associated with an increased prevalence of SMI. However, urban features alone cannot explain the variation observed in psychotic disorder prevalence or clinical outcomes measured through psychiatric hospitalisation or exposure to antipsychotic treatments.

Conclusion

Urban areas are associated with a greater prevalence of SMI but clinical outcomes are likely to depend on a combination of urban and individual patient-level factors. Future mental healthcare service planning should focus on providing appropriate resources to people with SMI in urban environments.

The associations between migrant status and ethnicity and the identification of individuals at ultra-high risk for psychosis and transition to psychosis: a systematic review

PURPOSE

Migrant and ethnic minority populations exhibit a higher incidence of psychotic disorders. The Ultra-High Risk for psychosis (UHR) paradigm provides an opportunity to explore the stage at which such factors influence the development of psychosis. In this systematic review, we collate and appraise the literature on the association between ethnicity and migrant status and the rate of identification of individuals at UHR, as well as their rate of transition to psychosis.

METHODS

We conducted a systematic review in the Ovid Medline, PsychINFO, Pubmed, CINAHL and EMBASE databases according to PRISMA guidelines. We included studies written in English that included an UHR cohort, provided a measure of ethnicity or migrant status, and examined the incidence, rate, or risk of UHR identification or transition to psychosis.

RESULTS

Of 2182 unique articles identified, seven fulfilled the criteria. One study found overrepresentation of UHR individuals from black ethnic groups, while another found underrepresentation. Two studies found increased rates of transition among certain ethnic groups and a further two found no association. Regarding migrant status, one study found that first-generation migrants were underrepresented in an UHR sample. Lastly, a lower transition rate in migrant populations was identified in one study, while two found no association.

CONCLUSION

Rates of UHR identification and transition according to ethnic and migrant status were inconsistent and insufficient to conclusively explain higher incidences of psychotic disorders among these groups. We discuss the clinical implications and avenues for future research, which is required to clarify the nature of the associations.

The Independent Effects of Psychosocial Stressors on Subclinical Psychosis: Findings From the Multinational EU-GEI Study

The influence of psychosocial stressors on psychosis risk has usually been studied in isolation and after the onset of the disorder, potentially ignoring important confounding relationships or the fact that some stressors that may be the consequence of the disorder rather than preexisting. The study of subclinical psychosis could help to address some of these issues. In this study, we investigated whether there was (i) an association between dimensions of subclinical psychosis and several psychosocial stressors including: childhood trauma, self-reported discrimination experiences, low social capital, and stressful life experiences, and (ii) any evidence of environment-environment (ExE) interactions between these factors. Data were drawn from the EUGEI study, in which healthy controls (N = 1497) and siblings of subjects with a psychotic disorder (N = 265) were included in six countries. The association between psychosocial stressors and subclinical psychosis dimensions (positive, negative and depressive dimension as measured by the Community Assessment of Psychic Experiences (CAPE) scale) and possible ExE interactions were assessed using linear regression models. After adjusting for sex, age, ethnicity, country, and control/sibling status, childhood trauma (β for positive dimension: 0.13, negative: 0.49, depressive: 0.26) and stressful life events (positive: 0.08, negative: 0.16, depressive: 0.17) were associated with the three dimensions. Lower social capital was associated with the negative and depression dimensions (negative: 0.26, depressive: 0.13), and self-reported discrimination experiences with the positive dimension (0.06). Our findings are in favor of independent, cumulative and non-specific influences of social adversities in subclinical psychosis in non-clinical populations, without arguments for E × E interactions.

Migrant status and identification as ultra-high risk for psychosis and transitioning to a psychotic disorder

BACKGROUND

Certain migrant groups are more likely to develop a psychotic disorder compared to the native-born populations, and a younger age at migration is associated with greater risk. However, it is not known at which stage migration has an effect on the development of psychotic disorders. We examined whether migrants were more likely to be identified as ultra-high risk for psychosis (UHR) compared to native-born young people and whether migrant status was associated with the risk of transition to a full-threshold psychotic disorder.

METHODS

The cohort included all young people aged 15-24 who were identified as UHR at a specialist clinic over a five-year period (2012-16). Australian census data were used to obtain the at-risk population. Poisson regression was used to calculate rate ratios and Cox regression analysis determined hazard ratios.

RESULTS

467 young people were identified as UHR, of which 13.5% (n = 63) were born overseas. First-generation migrants were 2.6-fold less likely to be identified as UHR compared to Australian-born young people (IRR = 0.39, 95% CI [0.30, 0.51], P < 0.001). There was no difference between migrant and native-born young people in their risk of transitioning to a psychotic disorder (HR = 0.90, 95% CI [0.39, 2.08], P = 0.81).

CONCLUSIONS

UHR first-generation migrants may be under-accessing mental health services.

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.

The relationship between ethnicity and service access, treatment uptake and the incidence of psychosis among people at ultra high risk for psychosis

Black ethnicity is associated with increased risk for psychosis in South London. This study explored the distribution of ethnicity among services users at ultra high risk for psychosis (UHR) and examined the influence of ethnicity on service access, treatment uptake and incidence of psychosis. The ethnic distribution of 228 people at UHR for psychosis, seen in an early detection clinical service over 10 years, was compared with 146 people with first episode psychosis from the same geographic region and census figures for the local population. Black service users were significantly over-represented in the UHR group compared to the background population (34% vs 21%; p < 0.05); but less so than in the first episode sample (58% vs 19%; p < 0.05). Within the UHR sample, there was no strong evidence of differences between ethnic groups in the types of treatment provided, nor in the rate of transition to psychosis over 2 years. The absence of differences between ethnic groups in rates of transition to psychosis raises the possibility that access to mental health care at the high risk stage might have reduced the influence of ethnicity on the incidence of psychosis in this sample. This would need to be replicated in a larger sample.

In the eye of the beholder: Perceptions of neighborhood adversity and psychotic experiences in adolescence

Adolescent psychotic experiences increase risk for schizophrenia and other severe psychopathology in adulthood. Converging evidence implicates urban and adverse neighborhood conditions in the etiology of adolescent psychotic experiences, but the role of young people's personal perceptions of disorder (i.e., physical and social signs of threat) in their neighborhood is unknown. This was examined using data from the Environmental Risk Longitudinal Twin Study, a nationally representative birth cohort of 2,232 British twins. Participants were interviewed at age 18 about psychotic phenomena and perceptions of disorder in the neighborhood. Multilevel, longitudinal, and genetically sensitive analyses investigated the association between perceptions of neighborhood disorder and adolescent psychotic experiences. Adolescents who perceived higher levels of neighborhood disorder were significantly more likely to have psychotic experiences, even after accounting for objectively/independently measured levels of crime and disorder, neighborhood- and family-level socioeconomic status, family psychiatric history, adolescent substance and mood problems, and childhood psychotic symptoms: odds ratio = 1.62, 95% confidence interval [1.27, 2.05], p < .001. The phenotypic overlap between adolescent psychotic experiences and perceptions of neighborhood disorder was explained by overlapping common environmental influences, rC = .88, 95% confidence interval [0.26, 1.00]. Findings suggest that early psychological interventions to prevent adolescent psychotic experiences should explore the role of young people's (potentially modifiable) perceptions of threatening neighborhood conditions.

Cumulative Effects of Neighborhood Social Adversity and Personal Crime Victimization on Adolescent Psychotic Experiences

BACKGROUND

Little is known about the impact of urbanicity, adverse neighborhood conditions and violent crime victimization on the emergence of adolescent psychotic experiences.

METHODS

Participants were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of 2232 British twins who were interviewed about adolescent psychotic experiences at age 18. Urbanicity, neighborhood characteristics, and personal victimization by violent crime were measured during childhood and adolescence via geocoded census data, surveys of over 5000 immediate neighbors of the E-Risk participants, and interviews with participants themselves.

RESULTS

Adolescents raised in urban vs rural neighborhoods were significantly more likely to have psychotic experiences (OR = 1.67, 95% CI = 1.21-2.30, P = .002). This association remained significant after considering potential confounders including family socioeconomic status, family psychiatric history, and adolescent substance problems (OR = 1.43, 95% CI = 1.01-2.03, P = .042), but became nonsignificant after considering adverse social conditions in urban neighborhoods such as low social cohesion and high neighborhood disorder (OR = 1.35, 95% CI = 0.94-1.92, P = .102). The combined association of adverse neighborhood social conditions and personal crime victimization with adolescent psychotic experiences (adjusted OR = 4.86, 95% CI = 3.28-7.20, P < .001) was substantially greater than for either exposure alone, highlighting a potential interaction between neighborhood conditions and crime victimization (interaction contrast ratio = 1.81, 95% CI = -0.03 to 3.65) that was significant at the P = .054 level.

CONCLUSIONS

Cumulative effects of adverse neighborhood social conditions and personal victimization by violent crime during upbringing partly explain why adolescents in urban settings are more likely to report psychotic experiences. Early intervention efforts for psychosis could be targeted towards victimized youth living in urban and socially adverse neighborhoods.

Neighbourhood deprivation is positively associated with detection of the ultra-high risk (UHR) state for psychosis in South East London

BACKGROUND

Individuals are defined as being at ultra-high risk (UHR) for psychosis based on a combination of attenuated psychotic symptoms, help-seeking behaviour, genetic risk, and social/occupational deterioration. Limited evidence is available on whether UHR detection differs by neighbourhood, and potential explanations.

AIMS

To examine neighbourhood distribution of detected UHR using cases from the OASIS service in South East London, investigating neighbourhood deprivation as an explanatory variable.

METHODS

Geographic data were collected on patients who met UHR criteria over a fourteen-year period, at the neighbourhood (lower super output area, LSOA) level. Rates were calculated based on cases and age-specific population estimates. Poisson regression assessed associations between UHR rate and neighbourhood deprivation, and with particular deprivation domains, adjusting for referrals for UHR assessment, population density, and proportions of non-White people, and young single people.

RESULTS

Rate of UHR detection was statistically related to neighbourhood deprivation, but referral rate was not: compared to the least deprived neighbourhoods, the most deprived neighbourhoods had a greater than two-fold increase in incidence rate of detected UHR (adjusted incidence rate ratio (IRR): 2.11, 95% confidence interval (CI): 1.21,3.67). In contrast, a small, imprecise association was observed for referral for assessment for UHR (adjusted IRR: 1.26 (95%CI: 0.84,1.89)). Evidence was also found for associations of UHR detection rate with domains of deprivation pertaining to health and barriers to services.

CONCLUSIONS

The distribution of UHR detection rates by neighbourhood is not random and may be explained in part by differences in the social environment between neighbourhoods.

Deconstructing Vulnerability for Psychosis: Meta-Analysis of Environmental Risk Factors for Psychosis in Subjects at Ultra High-Risk

Background

Subjects at ultra high-risk (UHR) for psychosis have an enhanced vulnerability to develop the disorder but the risk factors accounting for this accrued risk are undetermined.

Method

Systematic review of associations between genetic or environmental risk factors for psychosis that are widely established in the literature and UHR state, based on comparisons to controls.

Results

Forty-four studies encompassing 170 independent datasets and 54 risk factors were included. There were no studies on association between genetic or epigenetic risk factors and the UHR state that met the inclusion criteria. UHR subjects were more likely to show obstetric complications, tobacco use, physical inactivity, childhood trauma/emotional abuse/physical neglect, high perceived stress, childhood and adolescent low functioning, affective comorbidities, male gender, single status, unemployment and low educational level as compared to controls.

Conclusions

The increased vulnerability of UHR subjects can be related to environmental risk factors like childhood trauma, adverse life events and affective dysfunction. The role of genetic and epigenetic risk factors awaits clarification.

Why Are Children in Urban Neighborhoods at Increased Risk for Psychotic Symptoms? Findings From a UK Longitudinal Cohort Study

BACKGROUND

Urban upbringing is associated with a 2-fold adulthood psychosis risk, and this association replicates for childhood psychotic symptoms. No study has investigated whether specific features of urban neighborhoods increase children's risk for psychotic symptoms, despite these early psychotic phenomena elevating risk for schizophrenia and other psychiatric disorders in adulthood.

METHODS

Analyses were conducted on over 2000 children from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of UK-born twins. Neighborhood-level characteristics were assessed for each family via: a geodemographic discriminator indexing neighborhood-level deprivation, postal surveys of over 5000 residents living alongside the children, and in-home interviews with the children's mothers. Children were interviewed about psychotic symptoms at age 12. Analyses were adjusted for important family-level confounders including socioeconomic status (SES), psychiatric history, and maternal psychosis.

RESULTS

Urban residency at age-5 (OR = 1.80, 95% CI = 1.16-2.77) and age-12 (OR = 1.76, 95% CI = 1.15-2.69) were both significantly associated with childhood psychotic symptoms, but not with age-12 anxiety, depression, or antisocial behavior. The association was not attributable to family SES, family psychiatric history, or maternal psychosis, each implicated in childhood mental health. Low social cohesion, together with crime victimization in the neighborhood explained nearly a quarter of the association between urbanicity and childhood psychotic symptoms after considering family-level confounders.

CONCLUSIONS

Low social cohesion and crime victimization in the neighborhood partly explain why children in cities have an elevated risk of developing psychotic symptoms. Greater understanding of the mechanisms leading from neighborhood-level exposures to psychotic symptoms could help target interventions for emerging childhood psychotic symptoms.

Neighbourhood level social deprivation and the risk of psychotic disorders: a systematic review

PURPOSE

The incidence of psychotic disorders varies according to the geographical area, and it has been investigated whether neighbourhood level factors may be associated with this variation. The aim of this systematic review is to collate and appraise the literature on the association between social deprivation and the incidence or risk for psychotic disorders.

METHOD

A systematic review was conducted, and studies were included if they were in English, provided a measure of social deprivation for more than one geographically defined area and examined either the correlation, rate ratio or risk of psychotic disorder. A defined search strategy was undertaken with Medline, CINAHL Plus and PsychInfo databases.

RESULTS

A total of 409 studies were identified in the search, of which 28 fulfilled the inclusion criteria. Of these, four examined the association between social deprivation at the time of birth, three examined the putative prodrome of psychosis or those at ultra-high risk (UHR) for psychosis, and 23 examined the time at presentation with a first episode of psychosis (FEP) (one study examined two time points and one study included both UHR and FEP). Three of the studies that examined the level of social deprivation at birth found an association with a higher risk for psychotic disorders and increased social deprivation. Seventeen of the 23 studies found that there was a higher risk or rate of psychotic disorders in more deprived neighbourhoods at the time of presentation; however, adjusting for individual factors tended to weaken this association. Limited research has been conducted in the putative prodromal stage and has resulted in conflicting findings.

CONCLUSIONS

Research conducted to date has not definitively identified whether the association is a result of social causation or social drift; however, the findings do have significant implications for service provision, such as the location and access of services.

Neighbourhood characteristics and the incidence of first-episode psychosis and duration of untreated psychosis

BACKGROUND

The incidence of psychotic disorders varies between geographical areas and it has been hypothesized that neighbourhood-level factors may influence this variation. It is also plausible that the duration of untreated psychosis (DUP) is associated with neighbourhood characteristics. The aims of this study were to determine whether the incidence of first-episode psychosis (FEP) and the DUP are associated with the level of social deprivation, fragmentation, social capital and population density.

METHOD

All individuals with a FEP from a geographical defined catchment area over a 5-year period were included. Age-standardized incidence rates were calculated for each neighbourhood factor.

RESULTS

A total of 292 cases of FEP were included in the study and 45% had a diagnosis of a schizophrenia-spectrum disorder. The age standardized incidence rate of FEP in the most deprived area was 72.4 [95% confidence interval (CI) 26.4-162.7] per 100 000 person-years compared with 21.5 (95% CI 17.6-26.0) per 100 000 person-years in the most affluent areas. This represents a 3.4-fold increase in FEP incidence in the most deprived areas. The incidence of FEP was also increased in neighbourhoods that were more socially fragmented [incidence rate ratio (IRR) = 2.40, 95% CI 1.05-5.51, p = 0.04] and there was a trend for the incidence to be increased in neighbourhoods with lower social capital (IRR = 1.43, 95% CI 0.99-2.06, p = 0.05). The median DUP was 4 months and was higher in more socially fragmented neighbourhoods.

CONCLUSIONS

The incidence of psychotic disorders is related to neighbourhood factors and it may be useful to consider neighbourhood factors when allocating resources for early intervention services.

Understanding causes of and developing effective interventions for schizophrenia and other psychoses

Background

Early-intervention services (EISs) offer prompt and effective care to individuals with first-episode psychosis (FEP) and detect people at high risk (HR) of developing it.

Aims

We aimed to educate general practitioners about psychosis and guide their referrals to specialist care; investigate determinants of the transition of HR to FEP; and predict numbers of new cases to guide policy and service planning.

Incidence of psychosis in socially and ethnically diverse settings

We studied the incidence of new referrals for psychosis in a well-established EIS called CAMEO [seewww.cameo.nhs.uk(accessed 18 January 2016)] and built on other epidemiological studies. The overall incidence of FEP was 45.1 per 100,000 person-years [95% confidence interval (CI) 40.8 to 49.9 per 100,000 person-years]. This was two to three times higher than the incidence predicated by the UK Department of Health. We found considerable psychosis morbidity in diverse, rural communities.

Development of a population-level prediction tool for the incidence of FEP

We developed and validated a population-level prediction tool, PsyMaptic, capable of accurately estimating the expected incidence of psychosis [seewww.psymaptic.org/(accessed 18 January 2016)].

The Liaison with Education and General practiceS (LEGS) trial to detect HR

We tested a theory-based intervention to improve detection and referral of HR individuals in a cluster randomised controlled trial involving primary care practices in Cambridgeshire and Peterborough. Consenting practices were randomly allocated to (1) low-intensity liaison with secondary care, a postal campaign to help with the identification and referral of individuals with early signs of psychosis, or (2) the high-intensity theory-based intervention, which, in addition to the postal campaign, included a specialist mental health professional to liaise with each practice. Practices that did not consent to be randomised included a practice-as-usual (PAU) group. The approaches were implemented over 2 years for each practice between April 2010 and October 2013. New referrals were stratified into those who met criteria for HR/FEP (together: psychosis true positives) and those who did not fulfil such criteria (false positives). The primary outcome was the number of HR referrals per practice. Referrals from PAU practices were also analysed. We quantified the cost-effectiveness of the interventions and PAU using the incremental cost per additional true positive identified. Of 104 eligible practices, 54 consented to be randomised. Twenty-eight practices were randomised to low-intensity liaison and 26 practices were randomised to the high-intensity intervention. Two high-intensity practices withdrew. High-intensity practices referred more HR [incidence rate ratio (IRR) 2.2, 95% CI 0.9 to 5.1;p = 0.08], FEP (IRR 1.9, 95% CI 1.05 to 3.4;p = 0.04) and true-positive (IRR 2.0, 95% CI 1.1 to 3.6;p = 0.02) cases. High-intensity practices also referred more false-positive cases (IRR 2.6, 95% CI 1.3 to 5.0;p = 0.005); most (68%) of these were referred on to appropriate services. The total costs per true-positive referral in high-intensity practices were lower than those in low-intensity or PAU practices. Increasing the resources aimed at managing the primary–secondary care interface provided clinical and economic value.

The Prospective Analysis of At-risk mental states and Transitions into psycHosis (PAATH) study

We aimed to identify the proportion of individuals at HR who make the transition into FEP and to elucidate the common characteristics that can help identify them. Sixty help-seeking HR individuals aged 16–35 years were stratified into those who met the criteria for HR/FEP (true positives) according to the Comprehensive Assessment of At-Risk Mental States (CAARMS) and those who did not (false positives). HR participants were followed up over 2 years using a comprehensive interview schedule. A random sample of 60 healthy volunteers (HVs) matched for age (16–35 years), sex and geographical area underwent the same battery of questionnaires. Only 5% of our HR sample transitioned to a structured clinical diagnosis of psychosis over 2 years. HR individuals had a higher prevalence of moderate or severe depression, anxiety and suicidality than HVs. In fact, psychometric analyses in other population samples indicate that psychotic experiences measure the severe end of a common mental distress factor, consistent with these results. HR individuals also experienced significantly more traumatic events than HVs, but equivalent distress. Almost half of HR individuals had at least one Schneiderian first-rank symptom traditionally considered indicative of schizophrenia and 21.6% had more than one. HR individuals had very poor global functioning and low quality of life.

Conclusions

This National Institute for Health Research programme developed our understanding of the social epidemiology of psychosis. A new theory-based intervention doubled the identification of HR and FEP in primary care and was cost-effective. The HR mental state has much in common with depression and anxiety; very few people transitioned to full psychosis over 2 years, in line with other recent evidence. This new understanding will help people at HR receive appropriate services focused on their current mental state.

Trial registration

The primary LEGS trial is registered as ISRCTN70185866 and UKCRN ID 7036. The PAATH study is registered as UKCRN ID 7798.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

The role of vulnerability factors in individuals with an at-risk mental state of psychosis

BACKGROUND

Several indicators of heightened vulnerability to psychosis and relevant stressors have been identified. However, it has rarely been studied prospectively to what extent these vulnerability factors are in fact more frequently present in individuals with an at-risk mental state for psychosis. Moreover, it remains unknown whether any of these contribute to the prediction of psychosis onset in at-risk mental state individuals.

METHODS

There were 28 healthy controls, 86 first-episode psychosis patients and 127 at-risk mental state individuals recruited within the Basel "Früherkennung von Psychosen" project. Relative frequencies of selected vulnerability factors for psychosis were compared between healthy controls, psychosis patients, those at-risk mental state individuals with subsequent psychosis onset (n = 31) and those without subsequent psychosis onset (n = 55). Survival analyses were applied to determine associations between time to transition to psychosis and vulnerability factors in all 127 at-risk mental state individuals.

RESULTS

The vulnerability factors/indicators such as "difficulties during school education or vocational training", "difficulties during employment", "being single", "difficulties with intimate relationships" and "being burdened with specific stressful situations" were more commonly found in the at-risk mental state and first-episode psychosis group than in healthy controls.

CONCLUSIONS

At-risk mental state and first-episode psychosis individuals more frequently present with vulnerability factors. Individual vulnerability factors appear, however, not to be predictive for an onset of psychosis.

Social and spatial heterogeneity in psychosis proneness in a multilevel case-prodrome-control study

OBJECTIVE

To test whether spatial and social neighbourhood patterning of people at ultra-high risk (UHR) of psychosis differs from first-episode psychosis (FEP) participants or controls and to determine whether exposure to different social environments is evident before disorder onset.

METHOD

We tested differences in the spatial distributions of representative samples of FEP, UHR and control participants and fitted two-level multinomial logistic regression models, adjusted for individual-level covariates, to examine group differences in neighbourhood-level characteristics.

RESULTS

The spatial distribution of controls (n = 41) differed from UHR (n = 48; P = 0.04) and FEP participants (n = 159; P = 0.01), whose distribution was similar (P = 0.17). Risk in FEP and UHR groups was associated with the same neighbourhood-level exposures: proportion of single-parent households [FEP adjusted odds ratio (aOR): 1.56 95% CI: 1.00-2.45; UHR aOR: 1.59; 95% CI: 0.99-2.57], ethnic diversity (FEP aOR: 1.27; 95% CI: 1.02-1.58; UHR aOR: 1.28; 95% CI: 1.00-1.63) and multiple deprivation (FEP aOR: 0.88; 95% CI: 0.78-1.00; UHR aOR: 0.86; 95% CI: 0.76-0.99).

CONCLUSION

Similar neighbourhood-level exposures predicted UHR and FEP risk, whose residential patterning was closer to each other's than controls. Adverse social environments are associated with psychosis before FEP onset.