R Mallett

Incidence of schizophrenia and other psychoses in ethnic minority groups: results from the MRC AESOP study

BACKGROUND The incidence of schizophrenia in the African-Caribbean population in England is reported to be raised. We sought to clarify whether (a) the rates of other psychotic disorders are increased, (b) whether psychosis is increased in other ethnic minority groups, and (c) whether particular age or gender groups are especially at risk. METHOD We identified all people (n=568) aged 16-64 years presenting to secondary services with their first psychotic symptoms in three well-defined English areas (over a 2-year period in Southeast London and Nottingham and a 9-month period in Bristol). Standardized incidence rates and incidence rate ratios (IRR) for all major psychosis syndromes for all main ethnic groups were calculated. RESULTS We found remarkably high IRRs for both schizophrenia and manic psychosis in both African-Caribbeans (schizophrenia 9.1, manic psychosis 8.0) and Black Africans (schizophrenia 5.8, manic psychosis 6.2) in men and women. IRRs in other ethnic minority groups were modestly increased as were rates for depressive psychosis and other psychoses in all minority groups. These raised rates were evident in all age groups in our study. CONCLUSIONS Ethnic minority groups are at increased risk for all psychotic illnesses but African-Caribbeans and Black Africans appear to be at especially high risk for both schizophrenia and mania. These findings suggest that (a) either additional risk factors are operating in African-Caribbeans and Black Africans or that these factors are particularly prevalent in these groups, and that (b) such factors increase risk for schizophrenia and mania in these groups.

Incidence and outcome of schizophrenia in Whites, African-Caribbeans and Asians in London

BACKGROUND Several previous studies have indicated high rates of schizophrenia in African-Caribbeans in the UK compared to White population. METHOD All people aged 18 to 64 years residing in two health districts in London who made contact with hospital or community services over a 1-year (Whites) or 2-year (ethnic minorities) period were screened for psychotic symptoms. RESULTS One hundred and twenty-three patients passed the screen, of whom 100 were assigned a schizophrenic class by the CATEGO program. Of these, 38 were White, 38 African-Caribbean and 24 Asian. The incidence rate for broad schizophrenia was significantly higher for African-Caribbeans than for Whites. Asians showed a high rate among people age 30 and over, particularly women. Poor outcome at 1-year follow-up was significantly more common for African-Caribbeans than for the other two groups. The proportion of African-Caribbeans with a poor outcome was two and a half times greater than that of Whites. On a range of seven socio-demographic variables, African-Caribbeans differed from the other two groups only on unemployment. CONCLUSIONS A multitide of factors play a role in the aetiology of schizophrenia. Comparison of environmental factors in these groups may identify factors that contribute to the aetiology of schizophrenia.

Different effects of typical and atypical antipsychotics on grey matter in first episode psychosis: the ÆSOP Study

Typical antipsychotic drugs act on the dopaminergic system, blocking the dopamine type 2 (D2) receptors. Atypical antipsychotics have lower affinity and occupancy for the dopaminergic receptors, and a high degree of occupancy of the serotoninergic receptors 5-HT2A. Whether these different pharmacological actions produce different effects on brain structure remains unclear. We explored the effects of different types of antipsychotic treatment on brain structure in an epidemiologically based, nonrandomized sample of patients at the first psychotic episode. Subjects were recruited as part of a large epidemiological study (ÆSOP: aetiology and ethnicity in schizophrenia and other psychoses). We evaluated 22 drug-free patients, 32 on treatment with typical antipsychotics and 30 with atypical antipsychotics. We used high-resolution MRI and voxel-based methods of image analysis. The MRI analysis suggested that both typical and atypical antipsychotics are associated with brain changes. However, typicals seem to affect more extensively the basal ganglia (enlargement of the putamen) and cortical areas (reductions of lobulus paracentralis, anterior cingulate gyrus, superior and medial frontal gyri, superior and middle temporal gyri, insula, and precuneus), while atypical antipsychotics seem particularly associated with enlargement of the thalami. These changes are likely to reflect the effect of antipsychotics on the brain, as there were no differences in duration of illness, total symptoms scores, and length of treatment among the groups. In conclusion, we would like to suggest that even after short-term treatment, typical and atypical antipsychotics may affect brain structure differently.

Negative pathways to psychiatric care and ethnicity: the bridge between social science and psychiatry

It has been consistently reported that the African-Caribbean population in the UK are more likely than their White counterparts to access psychiatric services via the police and under compulsion. The reasons for these differences are poorly understood. This paper comprises two main parts. The first provides a comprehensive review of research in this area, arguing the current lack of understanding stems from a number of methodological limitations that characterise the research to date. The issue of ethnic variations in pathways to psychiatric care has been studied almost exclusively within a medical epidemiological framework, and the potential insights offered by sociological and anthropological research in the fields of illness behaviour and health service use have been ignored. This has important implications as the failure of research to move beyond enumerating differences in sources of referral to psychiatric services and rates of compulsory admission means no recommendations for policy or service reform have been developed from the research. The second part of the paper sets out the foundations for future research, arguing that the pathway to care has to be studied as a social process subject to a wide range of influences, including the cultural context within which illness is experienced. It is further argued that Kleinmans (Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine and psychiatry, University of California Press, Los Angeles, 1980) Health Care System model offers a particularly valuable preliminary framework for organising and interpreting future research. It is only through gaining a more qualitative understanding of the processes at work in shaping different responses to mental illness and interactions with mental health services that the patterns observed in quantitative studies can be fully understood. This further reflects the need for a bridge between the social sciences and psychiatry if services are to be developed to respond to the increasing diversity of modern societies.

Social environment, ethnicity and schizophrenia - A case-control study

Background There is accumulating evidence that genetic and neurodevelopmental factors cannot solely account for the pathogenesis of schizophrenia. In view of the reportedly increased incidence of schizophrenia among the African-Caribbean population in Britain, we sought to establish the socio-environmental influences which distinguished African-Caribbean patients from white British and Asian patients with schizophrenia, as well as from normal population controls of the same community. Method A matched case-control study was conducted in London between 1991 and 1993. Inclusion criteria for patients was a first onset psychosis between the ages of 18 and 64. Symptoms were recorded using the Present State Examination (PSE), and a research diagnosis of schizophrenia was made using the CATEGO program. Comparisons were made on a range of demographic and socio-environmental measures between patients (n = 100: 38 African-Caribbean, 38 white and 24 Asian) and the same number of normal controls. Results Three socio-environmental variables differentiated the African-Caribbean cases from their peers and their normal controls: unemployment, living alone and a long period of separation from either or both parents as a minor. Though all patients were much more likely than controls to be unemployed at first contact with the services (odds ratio 5.5, 95 % CI 2.59, 11.68), the odds ratio was highest among African-Caribbeans, and further conditional logistic regression analysis demonstrated that unemployment was significantly associated with the high rate of caseness among African-Caribbeans. However, the direction of cause and effect cannot be determined from this type of study. Despite the fact that African-Caribbean cases were more likely than their peers and same group controls to live alone (p < 0.05), this did not achieve significance using Fishers Exact Test. Separation from both parents in childhood distinguished African-Caribbean cases from their controls and from cases and controls of the other ethnic groups (odds ratio 5.0, 95 % CI 1.09, 22.82). This event cannot be attributed to the premorbid manifestations of schizophrenia, nor to psychoses in the parents, and hence is a possible explanatory factor for the high incidence of schizophrenia among African-Caribbeans in Britain. Conclusions These findings indicate that unemployment and early separation from both parents distinguish African-Caribbeans diagnosed with schizophrenia from their counterparts of other ethnic groups as well as their normal peers, and imply that more attention needs to be focussed on socio-environmental variables in schizophrenia research.

Fertility and marital rates in first-onset schizophrenia.

Background: Many studies have demonstrated that in schizophrenia there are decreased rates of marriage, fertility and marital fertility. However, it is not clear whether this finding occurs as a social consequence of having the illness or is an inherent part of the illness. One would expect it to vary across cultures if it were being mediated by social and cultural factors. Method: We investigated this by reviewing the marital and fertility data from a multi-ethnic first-contact group of patients in London with CATEGO broadly defined schizophrenia, and comparing this with similar data from a group of controls who were matched for age, gender and ethnicity. Results: Our sample comprised 38 White British, 38 Caribbean and 24 Asian subjects. The Asian group were significantly older (mean age 38, P < 0.003) and had a greater percentage of females (50%). When compared to controls, the White and Caribbean patients, but not the Asians, had decreased marital and stable relationship rates. There was also decreased fertility and marital fertility as evidenced by number of children among the Whites and Caribbeans, but again significantly not among the Asians. Marital status did not predict fertility rates, particularly among the Caribbeans. Regression analysis demonstrated an effect for age on the number of children but not on marital status. Conclusions: These findings suggest that marital and reproductive behaviour are reduced in schizophrenia, but this effect may be mediated by social and cultural factors and therefore not apply consistently across ethnicity. Further research is needed to prospectively investigate populations to determine whether impairments of this nature are inherent or consequential to the illness.

Cultural identity and its measurement: a questionnaire for Asians

Cultural identity is an integral part of an individuals self and it may affect social and individual functioning of individuals leading to mental distress.The present paper describes the key concepts of cultural identity such as religion, attitudes to the family, leisure activities, rites of passages, food and language.The concept of acculturation is vital to the concept of the self and thus the development of the self and degree of comfort in living within other cultures becomes important.The measurement of acculturation and cultural identity is often a difficult one. In this paper various measurements illustrate the need of having a multifaceted instrument in measuring cultural identity among Asians (those having connections with the Indian subcontinent).

Factors in the onset of schizophrenia: a comparison between London and Trinidad samples.

Objective: Sociodemographic factors play an important role in the genesis of mental disorders. High rates of unemployment and other social factors have been reported previously among African‐Caribbeans with schizophrenia in London. The aim of the present study was to compare these factors in Trinidad with London African‐Caribbeans.

Early manifestations, personality traits and pathways into care for Asian and white first-onset cases of schizophrenia

Abstract  Background: Previous studies have shown that manifestations of symptoms and premorbid personality of patients with schizophrenia differ across cultures. However, these have only been demonstrated in cultural settings apart from each other. Method: We set out to compare these across different ethnic groups from a catchment area in west London. The Asian and the white group had similar inception rates of schizophrenia and we therefore decided to compare these two groups to ascertain similarities in social, demographic and personality factors and pathways into care. First-onset cases of schizophrenia were studied on a number of parameters using previously validated instruments. Results: There were more similarities than differences between the two groups. When compared with the findings of a previous multicentre study in India, London Asians, like their counterparts in India, were more likely than the London white sample to present with loss of appetite, become more religious and behave as if hearing voices. However, compared to their Indian counterparts, the onset of symptoms was more likely to be insidious and alternative sources of healing were less likely to be approached. Conclusions: These findings are discussed in relation to the findings for white patients and recommendations made for future research.

Schizophrenia and African-Caribbeans: a conceptual model of aetiology

Several studies in the UK have observed that the inception rates of schizophrenia among the African-Caribbeans are well elevated when compared withWhite populations.However, on the basis of available data on biological factors it appears that social factors play a more important role in the aetiology of schizophrenia in this group. Reviewing the current state of literature on self-esteem and social factors it is proposed that lack of early attachments and prolonged separation from one or both parents may well play a significant role in the genesis of schizophrenia in this group. It is proposed that some of these factors mediate through low self-esteem and the clinicians and researchers alike are urged to explore further the role of self-esteem in genesis and maintenance of symptoms of schizophrenia.