Ethnic inequalities in the incidence of diagnosis of severe mental illness in England: a systematic review and new meta-analyses for non-affective and affective psychoses.

PURPOSE: Although excess risks particularly for a diagnosis of schizophrenia have been identified for ethnic minority people in England and other contexts, we sought to identify and synthesise up-to-date evidence (2018) for affective in addition to non-affective psychoses by specific ethnic groups in England. METHODS: Systematic review and meta-analysis of ethnic differences in diagnosed incidence of psychoses in England, searching nine databases for reviews (citing relevant studies up to 2009) and an updated search in three databases for studies between 2010 and 2018. Studies from both searches were combined in meta-analyses allowing coverage of more specific ethnic groups than previously. RESULTS: We included 28 primary studies. Relative to the majority population, significantly higher risks of diagnosed schizophrenia were found in Black African (Relative risk, RR 5.72, 95% CI 3.87-8.46, n = 9); Black Caribbean (RR 5.20, 95% CI 4.33-6.24, n = 21); South Asian (RR 2.27, 95% CI 1.63-3.16, n = 14); White Other (RR 2.24, 95% CI 1.59-3.14, n = 9); and Mixed Ethnicity people (RR 2.24, 95% CI 1.32-3.80, n = 4). Significantly higher risks for diagnosed affective psychoses were also revealed: Black African (RR 4.07, 95% CI 2.27-7.28, n = 5); Black Caribbean (RR 2.91, 95% CI 1.78-4.74, n = 16); South Asian (RR 1.71, 95% CI 1.07-2.72, n = 8); White Other (RR 1.55, 95% CI 1.32-1.83, n = 5); Mixed Ethnicity (RR 6.16, 95% CI 3.99-9.52, n = 4). CONCLUSIONS: The risk for a diagnosis of non-affective and affective psychoses is particularly elevated for Black ethnic groups, but is higher for all ethnic minority groups including those previously not assessed through meta-analyses (White Other, Mixed Ethnicity). This calls for further research on broader disadvantages affecting ethnic minority people.

[Cultural aspects in depression masked by psychotic symptoms in Maghreb countries: three case reports]. / Aspects culturels dans la dépression masquée par des symptômes psychotiques.

CASE REPORTS: In this study, we will describe three observations of depression "masked" by persecution delirium and/or hallucinations, to illustrate the role that the cultural factor could play in the expression and care of depression. In the first two observations, the persecutor was a group that was apparently difficult to circumscribe: the persecution appeared more important than the persecutor. In these two cases, persecution also had a depreciating role for the patient. In the third observation, the hallucinatory manifestations cast a slur on self-esteem and caused narcissistic injury. DISCUSSION: Analysis of the cultural context allows us to understand the depressive significance of such psychotic symptoms. In the traditional societies, depression is strongly related to the cultural context, it is often expressed by the fear of being punished or denied by the group, and a feeling of treason towards the community. The punishment can be direct or indirect, carried out by imaginary beings, "the djinn", or by any disease. According to Freud, the guilt is expressed by the fear of the vengeance of a dead man's spirit, which is then going to persecute the culprit. This persecution, which has a value of punishment, is based on the mechanism of the projection. In the same sense, Freud explained that the death, as a sequel of the disease, is the vengeance of the dead man's spirit in the living. In all religions, the impulses, the thoughts disapproved by the community, are attributed to Satan who etymologically means "the enemy" or "the opponent". This latter plays an important role in relieving fears, the sense of guilt and the disapproved thoughts. There is also involvement of the projection mechanism. So, guilt could be expressed by delirious ideas such as the conviction of being the victim of a demonic possession, to be under a spell or to be persecuted. CONCLUSION: Thus, taking the cultural context into account would allow us to fundamentally understand the depressive meaning of the delirious symptomatology of persecution, which is taken from a popular theory of misfortune shared and validated by the familial and the social circle of acquaintances. Plantine postulates that the psychotic conflict takes the subject away from the standards of his own culture. In the case of our three patients, we should try to establish a form of communication, to prevent them from falling into alienation. Thus, we must think about our attitude facing a patient who is diagnosed as depressed or even psychotic, while the patient believes he/she is possessed by a "Djinn". The therapeutic attitude should be adapted to the cultural dimension of the case. Thus, in situations similar to the studied cases, the therapy should be essentially based on the development of a psychotherapeutic relationship, rather than a pharmacotherapy, one should be careful not to compromise the cultural means of restoring psychic disorders such as the traditional therapy.

Raised incidence rates of all psychoses among migrant groups: findings from the East London first episode psychosis study.

CONTEXT: Certain black and minority ethnic groups are at increased risk for psychoses. It is unknown whether risk for second- and later-generation black and minority ethnic groups in the United Kingdom is universally increased or varies by ethnicity, population structure, or diagnostic category. OBJECTIVES: To examine whether excess risk in black and minority ethnic groups varies by generation status and to determine whether this is explained solely by an excess of broadly defined schizophrenia. DESIGN: Population-based epidemiological survey of first-onset psychoses during a 2-year study period. SETTING: Three inner-city boroughs in East London, England. Patients Four hundred eighty-four patients with first-episode psychosis aged 18 to 64 years. MAIN OUTCOME MEASURES: Nonaffective or affective psychoses according to the DSM-IV. RESULTS: Raised incidence of both nonaffective and affective psychoses were found for all of the black and minority ethnic subgroups compared with white British individuals. The risk of nonaffective psychoses for first and second generations varied by ethnicity (likelihood ratio test, P = .06). Only black Caribbean second-generation individuals were at significantly greater risk compared with their first-generation counterparts (incidence rate ratio, 2.2; 95% confidence interval, 1.1-4.2) [corrected]. No significant differences between first and second generations were observed in other ethnic groups. Asian women but not men of both generations were at increased risk for psychoses compared with white British individuals. Patterns were broadly upheld for the affective psychoses. CONCLUSIONS: Both first- and second-generation immigrants were at elevated risk for both nonaffective and affective psychoses, but this varied by ethnicity. Our results suggest that given the same age structure, the risk of psychoses in first and second generations of the same ethnicity will be roughly equal. We suggest that socioenvironmental factors operate differentially by ethnicity but not generation status, even if the exact specification of these stressors differs across generations. Research should focus on differential rates of psychoses by ethnicity rather than between generations.

Neurological abnormalities and cognitive ability in first-episode psychosis.

BACKGROUND: It remains unclear if the excess of neurological soft signs, or of certain types of neurological soft signs, is common to all psychoses, and whether this excess is simply an epiphenomenon of the lower general cognitive ability present in psychosis. AIMS: To investigate whether an excess of neurological soft signs is independent of diagnosis (schizophrenia v. affective psychosis) and cognitive ability (IQ). METHOD: Evaluation of types of neurological soft signs in a prospective cohort of all individuals presenting with psychoses over 2 years (n=310), and in a control group from the general population (n=239). RESULTS: Primary (P<0.001), motor coordination (P<0.001), and motor sequencing (P<0.001) sign scores were significantly higher in people with any psychosis than in the control group. However, only primary and motor coordination scores remained higher when individuals with psychosis and controls were matched for premorbid and current IQ. CONCLUSIONS: Higher rates of primary and motor coordination signs are not associated with lower cognitive ability, and are specific to the presence of psychosis.

Neighbourhood variation in the incidence of psychotic disorders in Southeast London.

BACKGROUND: Urbanicity is a risk factor for schizophrenia, but it is unclear whether this risk is homogenous across urban areas. AIMS: To determine whether the incidence of psychotic disorders varied within an urban area, beyond variation attributable to individual-level characteristics. METHODS: All incident cases of ICD-10 psychoses from a large, 2-year, epidemiological study of first-episode psychoses in Southeast London were identified. Incidence rates for 33 wards were standardised for age, sex and ethnicity. Bayesian models produced accurate relative risk estimates that were then mapped. RESULTS: 295 cases were identified during 565,000 person-years of follow-up. We observed significant heterogeneity in relative risks for broad and non-affective psychoses (schizophrenia), but not for affective psychoses. Highest risks were observed in contiguous wards. CONCLUSIONS: Neighbourhood variation in the incidence of non-affective psychoses could not be explained by individual-level risk, implicating neighbourhood-level socioenvironmental factors in their aetiology. The findings are consistent with classical sociological models of mental disorders.

Minor physical anomalies across ethnic groups in a first episode psychosis sample.

Minor physical anomalies (MPAs) are more prevalent amongst individuals with psychosis, supporting a neurodevelopmental model for psychotic disorders. The aim of this study was to investigate the possibility that neurodevelopmental adversity contributes to the excess of psychosis found in some ethnic groups in the UK. Subjects with first onset psychosis and healthy neighbourhood controls were enrolled in the AESOP study in South East London and Nottingham between 1997 and 1999. MPA rates were estimated in four broad ethnic groupings (White, African Caribbean, Black African and Other). Patients (n=245) had a higher mean total MPA score than healthy controls (n=158). This held true across each of the four ethnic groupings. The results of this study suggest that neurodevelopmental factors play a role in the aetiology of psychosis across all ethnic groups.

Care patterns for affective psychosis across diverse ethnicities: exploring potential contributors to complications and emergency room utilization.

OBJECTIVE: To explore associations between access to care and environmental stressors with emergency room admissions; to evaluate patterns of complications across diverse ethnic groups related to affective psychosis. METHODS: Data from the National Inpatient Sample were used to evaluate complications and frequency of hospitalization through the emergency room as a proportion of all hospital admissions for affective psychosis across diverse ethnic groups. Unemployment data, variations of trends of proportions of emergency room admissions after the September 11th tragedy, and ratios of primary care physicians/psychiatrists to the general population were evaluated. RESULTS: Admissions through the emergency room as a percentage of all admissions for affective psychosis decreased from 1995 through 1999 but increased in 2001, showing a potential association with increasing unemployment rates and the September 11th tragedy. Over the same period, relatively higher frequencies of emergency room admissions as a proportion of all hospital admissions among African Americans decreased. No significant differences for complications or emergency room utilization were observed between African Americans and Whites by 2001. During the entire period, frequencies of complications in the Hispanic and Asian populations remained lower than frequencies in both African American and White populations. No associations were found between physician-to-population ratios and utilization of the emergency room. CONCLUSION: Patterns of emergency room utilization and complications in African American and White populations appear to show some association with environmental stressors. Further study is warranted to evaluate protective factors associated with lower risk of complications in both Hispanic and Asian populations.

Ethnic matching of clients and clinicians and use of mental health services by ethnic minority clients.

OBJECTIVES: Research in the United States has indicated that matching clients from a minority group with clinicians from the same ethnic background increases use of community mental health services and reduces use of emergency services. This study assessed the effects of matching clients from a non-English-speaking background with bilingual, bicultural clinicians in a mental health system in Australia that emphasizes community-based psychiatric case management. METHODS: In an overall sample of 2,935 clients served in the western region of Melbourne from 1997 to 1999, ethnic minority clients from a non-English-speaking background who received services from a bilingual, bicultural case manager were compared with ethnic minority clients who did not receive such services and with clients from an English-speaking background. The clients' engagement with three types of services-community care teams, psychiatric crisis teams, and psychiatric inpatient services-was assessed. RESULTS: Compared with ethnic minority clients who were not matched with a bilingual clinician, those who were matched generally had a longer duration and greater frequency of contact with community care teams and a shorter duration and lower frequency of contact with crisis teams. Clients born in Vietnam who were matched with a bilingual clinician had a shorter annual mean length of hospital stay and a lower annual mean frequency of hospital admission than Australian-born clients. CONCLUSIONS: The benefits of matching clients with psychiatric case managers on the basis of ethnic background include a lower level of need for crisis intervention and, for clients from some ethnic groups, fewer inpatient interventions. These Australian results support findings of the effectiveness of client-clinician ethnic matching in the United States.

Delineation of acute and transient psychotic disorders in a developing country setting.

BACKGROUND: We examined whether acute transient psychoses can be distinguished from schizophrenia and the affective disorders. METHOD: We studied 46 cases of nonaffective acute psychosis in the Chandigarh Acute Psychosis Study. With respect to separation from schizophrenia, we examined the distribution of duration of the episode. With respect to separation from affective disorders, we assessed the frequency of affective symptoms. RESULTS: Duration was bimodal, suggesting the presence of two distinct conditions of short and long duration. Affective symptoms were minimal, suggesting that these were not atypical affective syndromes. CONCLUSIONS: Acute transient psychoses conform neither with schizophrenia of brief duration nor with atypical affective psychosis, and thus require separate classification as proposed in the ICD-10.

Race and tardive dyskinesia among outpatients at a CMHC.

OBJECTIVE: In a previous study of outpatients with chronic mental illness who were treated with neuroleptic medication, the authors found a higher incidence of tardive dyskinesia among blacks than among whites. In this study the authors examined psychosocial, clinical, treatment, and medical correlates of race that might explain this finding. METHODS: Extensive baseline data were obtained for 398 outpatients at risk for tardive dyskinesia. Pearson and Mantel-Haenszel chi square analyses were used to determine significant associations between a large number of variables and race. RESULTS AND DISCUSSION: Compared with whites, nonwhites were more likely to be younger, less skilled, and unmarried; to report contacts with relatives outside the home; to have a diagnosis of schizophrenia; and to receive higher doses of neuroleptic drugs primarily through depot medications. Nonwhites were less likely to receive nonneuroleptic psychotropics, to wear dentures, and to report social contact with fathers. None of these racial differences explained more than a trivial portion of the association between race and the incidence of tardive dyskinesia. CONCLUSIONS: These results suggest the need for studies of differences in diagnostic and prescribing practices for black and white patients and of differences in the action and side effects of neuroleptics.

The prevalence and nature of lithium noncompliance among Chinese psychiatric patients in Hong Kong.

Based on the multiple criteria of serum lithium level, patients' subjective report and doctors' impression in the previous year, a noncompliance rate of 30% was found among 50 Chinese patients on chronic lithium treatment in Hong Kong. Of numerous variables analyzed, only lithium monotherapy, younger age, and earlier age of onset were significantly associated with noncompliance. Exploratory interviews documented the multidimensionality of lithium noncompliance. They argued against statistical attempts to establish a universal clinical formula for the prediction of lithium noncompliance, and underscored the personal, social and medical contexts in which illnesses were lived and treatments used. For cultural reasons, familiar Western rationales for legitimating lithium noncompliance, such as missing of highs, loss of assertiveness, loss of creativity, and excessive fear of weight gain, were rarely encountered. After 1 1/2-years of attendance and with specific interventions at the lithium clinic, the noncompliance rate decreased from 30% to 14%. The important role of a parent-child-dominated Chinese kinship system in the chronic care of psychiatric patients is also discussed.