Rates of psychotic disorders vary widely across the globe, according to results of an international study that investigated the incidence of psychotic disorders across 17 catchment areas in six countries.
In line with previous research, investigators found higher rates of psychotic disorders in racial/ethnic minority groups and among young people, particularly for men, although there was also a “small but robust” secondary peak in risk for psychosis in women older than 45 years.
This study confirmed “marked heterogeneity” in risk for psychotic disorders by person and place, “indicating that both individual and catchment area-level risk factors are important in predicting incidence,” write the authors.
The study was published online December 6 in JAMA Psychiatry.
Incidence Highly Variable
James Kirkbride, PhD, from University College London, United Kingdom, and colleagues estimated the incidence of psychotic disorders in two catchment areas in the United Kingdom, three each in France and Italy, two in the Netherlands, six in Spain, and one in Brazil.
The study included 2774 adults (1196 women; median age, 30.5 years) who sought care for a first episode of psychosis (FEP). Most patients (2183, 79%) had nonaffective psychotic disorders.
The overall incidence of psychotic disorders was 21.4 per 100,000 person-years, but there was wide variation between areas. The crude incidence of FEP varied tenfold across catchment areas, from 6.3 cases per 100,000 in Santiago, Spain, to 61.4 cases per 100,000 person-years in southeast London, England.
After adjusting for age, sex, and ethnic makeup of the population across catchment areas, an eightfold variation was seen in the incidence of all psychotic disorders, from 6.0% per 100,000 person-years in Santiago to 46.1 per 100,000 in Paris, France.
Rates of FEP were lower in catchment areas in which there was a higher proportion of owner-occupied homes, a proxy for social stability and cohesion, “implicating socioeconomic factors in the presentation of psychotic disorders, in line with findings of previous research,” the authors note.
Rates of psychosis were elevated 1.6-fold in racial/ethnic minority groups and were highest in men aged 18 to 24 years. Unexpectedly, a lower incidence of affective psychoses was associated with higher area-level unemployment.
More Questions Than Answers
The authors of a linked editorial describe the study as “an integral part of a broader scientific initiative focused on gene-environment interactions, the European Network of National Schizophrenia Networks Studying Gene-Environment Interactions.”
Despite various caveats, which they delve into in their editorial, Ezra Susser, MD, Columbia University in New York City, and Gonzalo Martínez-Alés, MD, of La Paz University Hospital in Madrid, Spain, write that “it seems likely that much of the unexplained variation reported here is real. It also seems likely that part of it is explained by as-yet unidentified sociocultural differences between settings.
“There is a long history of research on the social determinants of psychoses. Building primarily on the tradition of social ecologic research, this study shows how far this field has advanced and how far it has yet to go,” they write. “We now have strong evidence that social experiences influence individual brain development and some evidence about the kinds of social context that may play a role in the trajectory toward psychosis onset.”
Dr Susser and Dr Martínez-Alés note that the results of this study “underscore the need to continue to refine both theories and measurements of the relationships between sociocultural environmental factors and psychoses, to seize opportunities to examine interactions at multiple, strategically chosen levels via strong study designs, and to use new opportunities to extend these studies across the globe.”
This new study “raises more questions than it answers, demonstrating how much we can still learn. We hope that it will spur further international efforts to explore how variation in sociocultural environments might be associated with psychosis incidence,” they conclude.
The study had no commercial funding. The authors and editorialists have disclosed no relevant financial relationships.
JAMA Psychiatry. Published online December 6, 2017. Abstract, Editorial
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