Poor, Urban Environments Linked to Higher Psychosis Risk

Pam Harrison

October 31, 2016

People who live in more urban and deprived communities are more likely to experience a first episode of psychosis than those who live in the most rural and wealthy regions in the same geographic area, a large epidemiologic study suggests.

"Previous studies have suggested that the more urban the environment, the greater one's risk of developing psychotic disorder, and this includes studies which have examined the association between urban birthplace and later risk," James Kirkbride, PhD, University College London, United Kingdom, told Medscape Medical News in an email.

"But few studies have examined whether rates also vary within rural populations, and we felt this needed addressing," he added.

"What we found in this rural population suggested that rates followed classical patterns by age (younger at more risk), sex (higher for men) and ethnicity (higher amongst minority groups) but more interestingly, rates were fairly stable across our study region until we looked at the most urban and the most deprived communities, and here rates increased substantially," Dr Kirkbride noted.

"And our study shows that people in the poorest urban communities face a particularly high risk of psychosis," he said in a statement.

The study was published online October 24 in the American Journal of Psychiatry.

Naturalistic Study

The Social Epidemiology of Psychoses in East Anglia (SEPEA) study is a naturalistic cohort study that includes a diverse mixture of rural and urban settings in the east of England.

"We identified all persons aged 16 to 35 years who presented to six early intervention in psychosis [EIP] services in a defined catchment area over 3.5 years," said Dr Kirkbride.

Of all individuals presenting to EIP services during the study period, 687 patients were diagnosed with psychotic disorder; of those patients, approximately 51% were diagnosed as having schizophrenia.

On average, this corresponds to approximately 3 of every 10,000 people who develop a first episode of psychosis every year in this particular catchment area.

The median age at the time of the first referral was similar for men and women, at 22.5 and 23.4 years, respectively.

Not unexpectedly, two thirds of the new diagnoses were in men.

"Compared to the population at risk, cases were also more likely to be younger, from an ethnic minority background, to be single, to be unemployed and to be of lower socioeconomic status," said Dr Kirkbride (P < .01 for all endpoints).

Importantly, those presenting with their first psychotic episode during the study period were also significantly more likely to come from more deprived and densely populated neighborhoods compared with the population at risk, the investigators note.

For example, rates of first-episode psychosis were 47% higher in ethnic minority populations than in the white British population.

Generalizable Results

Individuals who lived in more urban and deprived communities were from 40% to 100% more likely to experience first-episode psychosis than individuals from the most rural and wealthy regions of East Anglia, the investigators added in a statement.

Knowing that rates of psychotic disorder can be expected to be higher in deprived communities in both rural and urban areas is important in terms of helping planners assess the area's needs for mental health services, the investigators note.

"Until now, relatively few studies have been conducted in rural populations. But it's important to address this because early intervention in psychosis teams need to know about incidence rates that they will expect in their services," he said.

Dr Kirkbride also believes that although every environment is different, results from the SEPEA study should apply beyond the region of East Anglia.

"We have previously shown that we can use epidemiological data such as these to forecast the expected need for services in other regions," said Dr Kirkbride.

"The next step which we're currently preparing is to see whether we can extend this process to other countries where EIP services require information about expected service demands as well."

Dr. Kirkbride and colleagues recently launched PsyMaptic (www.psymaptic.org), a free online prediction tool for healthcare planners who require reliable data on the expected incidence of psychotic disorders in England and Wales.

Dr Kirkbride is supported by the Sir Henry Wellcome research fellowship from the Wellcome Trust and by a Shire Henry Dale fellowship jointly funded by the Wellcome Trust and by the Royal Society.

Am J Psychiatry. Published online October 24, 2016. Abstract

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