Ethnoracial Risk Variation Across the Psychosis Continuum in the US: A Systematic Review and Meta-Analysis

Importance

Studies suggest a higher risk of schizophrenia diagnoses in Black vs White Americans, yet a systematic investigation of disparities that include other ethnoracial groups and multiple outcomes on the psychosis continuum is lacking.

Objective

To identify ethnoracial risk variation in the US across 3 psychosis continuum outcomes (ie, schizophrenia and other psychotic disorders, clinical high risk for psychosis [CHR-P], and psychotic symptoms [PSs] and psychotic experiences [PEs]).

Data Sources

PubMed, PsycINFO and Embase were searched up to December 2022.

Study Selection

Observational studies on ethnoracial differences in risk of 3 psychosis outcomes.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Using a random-effects model, estimates for ethnoracial differences in schizophrenia and PSs/PEs were pooled and moderation by sampling and setting was determined, along with the assessment of heterogeneity and risk of bias.

Main Outcomes and Measures

Risk of schizophrenia and other psychotic disorder, CHR-P, and conversion to psychosis among CHR-P and PSs/PEs.

Results

Of 64 studies in the systematic review, 47 were included in the meta-analysis comprising 54 929 people with schizophrenia and 223 097 with data on PSs/PEs. Compared with White individuals, Black individuals had increased risk of schizophrenia (pooled odds ratio [OR], 2.07; 95% CI, 1.64-2.61) and PSs/PEs (pooled standardized mean difference [SMD], 0.10; 95% CI, 0.03-0.16), Latinx individuals had higher risk of PSs/PEs (pooled SMD, 0.15; 95% CI, 0.08-0.22), and individuals classified as other ethnoracial group were at significantly higher risk of schizophrenia than White individuals (pooled OR, 1.81; 95% CI, 1.31-2.50). The results regarding CHR-P studies were mixed and inconsistent. Sensitivity analyses showed elevated odds of schizophrenia in Asian individuals in inpatient settings (pooled OR, 1.84; 95% CI, 1.19-2.84) and increased risk of PEs among Asian compared with White individuals, specifically in college samples (pooled SMD, 0.16; 95% CI, 0.02-0.29). Heterogeneity across studies was high, and there was substantial risk of bias in most studies.

Conclusions and Relevance

Findings of this systematic review and meta-analysis revealed widespread ethnoracial risk variation across multiple psychosis outcomes. In addition to diagnostic, measurement, and hospital bias, systemic influences such as structural racism should be considered as drivers of ethnoracial disparities in outcomes across the psychosis continuum in the US.

Consent for Research Involving Spanish- and English-Speaking Latinx Adults With Schizophrenia

BACKGROUND

Latinxs are vastly underrepresented in mental health research; one of many contributing factors may be complexities in the research consent process, including language preferences. We examined determinants of comprehension of research consent procedures and tested the effects of a preconsent research schema condition among 180 adults with schizophrenia (60 Latinx-English and 60 Latinx-Spanish preference, and 60 non-Latinx White).

STUDY DESIGN

Participants were randomly assigned (equal allocation) to an educational session regarding clinical research concepts and processes (schema condition) or to an attention control. Following a subsequent simulated consent procedure for a hypothetical drug trail, comprehension of consent disclosures was measured with 2 standard measures.

STUDY RESULTS

One-way ANOVAs showed significant medium effect size differences between ethnicity/language groups on both measures of comprehension (η2s = 0.066-0.070). The Latinx-Spanish group showed lower comprehension than non-Latinx White participants; differences between the 2 Latinx groups did not reach statistical significance. Group differences were not statistically significant after adjusting for differences in education, or on scores from structured measures of acculturation, health literacy, or research literacy. Two-way ANOVAs showed no significant main effects for consent procedure on either comprehension measure (Ps > .369; partial η2s < 0.006) and no significant group-by-consent interactions (Ps > .554; partial η2s < 0.008).

CONCLUSIONS

Although the preconsent procedure was not effective, the results suggest health and research literacy may be targets for reducing disparities in consent comprehension. The onus is on researchers to improve communication of consent information as an important step to addressing health care disparities.

"It's Tough to Be a Black Man with Schizophrenia": Randomized Controlled Trial of a Brief Video Intervention to Reduce Public Stigma

BACKGROUND AND HYPOTHESIS

Racial discrimination and public stigma toward Black individuals living with schizophrenia create disparities in treatment-seeking and engagement. Brief, social-contact-based video interventions efficaciously reduce stigma. It remains unclear whether including racial identity experiences in video narrative yields greater stigma reduction. We hypothesized that we would replicate findings showing sustained stigma reduction in video-intervention groups vs control and that Black participants would show greater stigma reduction and emotional engagement than non-Black participants only for a racial-insights video presenting a Black protagonist.

STUDY DESIGN

Recruiting using a crowdsourcing platform, we randomized 1351 participants ages 18-30 to (a) brief video-based intervention, (b) racial-insights-focused brief video, or (c) non-intervention control, with baseline, post-intervention, and 30-day follow-up assessments. In 2-minute videos, a young Black protagonist described symptoms, personal struggles, and recovery from schizophrenia, with or without mentioning race-related experiences.

STUDY RESULTS

A 3 × 3 ANOVA showed a significant group-by-time interaction for total scores of each of five stigma-related domains: social distance, stereotyping, separateness, social restriction, and perceived recovery (all P < .001). Linear mixed modeling showed a greater reduction in stigma from baseline to post-intervention among Black than non-Black participants in the racial insights video group for the social distance and social restriction domains.

CONCLUSIONS

This randomized controlled trial replicated and expanded previous findings, showing the anti-stigma effects of a brief video tailored to race-related experiences. This underscores the importance of personalized, culturally relevant narratives, especially for marginalized groups who, more attuned to prejudice and discrimination, may particularly value identification and solidarity. Future studies should explore mediators/moderators to improve intervention efficacy.

Comparison of Black and white individuals who report diagnoses of schizophrenia in a national sample of US adults: Discrimination and service use

BACKGROUND

While there is increasing recognition of disparities in healthcare for Black Americans, there have been no comparisons in a nationally representative U.S. sample of Black and White adults with clinical diagnoses of schizophrenia.

METHODS

Using nationally representative survey data from the National Epidemiologic Survey on Alcohol and Related Conditions-III, we compared Black (n = 240, 36.2%) and White (n = 423, 63.8%) adults who report having been told by a physician that they have schizophrenia. Due to the large sample size, effect sizes (risk ratios and Cohen's d), rather than p-values, were used to identify the magnitude of differences in sociodemographic and clinical characteristics, including experiences of discrimination and service use. Multivariate analyses were used to identify independent factors.

RESULTS

Black individuals with diagnoses of schizophrenia reported multiple sociodemographic disadvantages, including lower rates of employment, educational attainment, income, marriage, and social support, with little difference in incarceration, violent behavior, and quality of life. They reported much higher scores on a general lifetime discrimination scale (Cohen's d = 0.75) and subscales representing job discrimination (d = 0.85), health system discrimination (d = 0.70), and public race-based abuse (d = 0.55) along with higher rates of past year alcohol and drug use disorders, but lower rates of co-morbid psychiatric disorders. Multivariable-adjusted regression analyses highlighted the independent association of Black race with measures of discrimination and religious service attendance; less likelihood of receiving psychiatric treatment (p = 0.02) but no difference in substance use treatment.

CONCLUSION

Black adults with schizophrenia report numerous social disadvantages, especially discrimination, but religious service attendance may be an important social asset.

Social disadvantage, linguistic distance, ethnic minority status and first-episode psychosis: results from the EU-GEI case-control study

BACKGROUND

Ethnic minority groups in Western countries face an increased risk of psychotic disorders. Causes of this long-standing public health inequality remain poorly understood. We investigated whether social disadvantage, linguistic distance and discrimination contributed to these patterns.

METHODS

We used case-control data from the EUropean network of national schizophrenia networks studying Gene-Environment Interactions (EU-GEI) study, carried out in 16 centres in six countries. We recruited 1130 cases and 1497 population-based controls. Our main outcome measure was first-episode ICD-10 psychotic disorder (F20-F33), and exposures were ethnicity (white majority, black, mixed, Asian, North-African, white minority and other), generational status, social disadvantage, linguistic distance and discrimination. Age, sex, paternal age, cannabis use, childhood trauma and parental history of psychosis were included as a priori confounders. Exposures and confounders were added sequentially to multivariable logistic models, following multiple imputation for missing data.

RESULTS

Participants from any ethnic minority background had crude excess odds of psychosis [odds ratio (OR) 2.03, 95% confidence interval (CI) 1.69-2.43], which remained after adjustment for confounders (OR 1.61, 95% CI 1.31-1.98). This was progressively attenuated following further adjustment for social disadvantage (OR 1.52, 95% CI 1.22-1.89) and linguistic distance (OR 1.22, 95% CI 0.95-1.57), a pattern mirrored in several specific ethnic groups. Linguistic distance and social disadvantage had stronger effects for first- and later-generation groups, respectively.

CONCLUSION

Social disadvantage and linguistic distance, two potential markers of sociocultural exclusion, were associated with increased odds of psychotic disorder, and adjusting for these led to equivocal risk between several ethnic minority groups and the white majority.

Schizophrenia hospitalization in the US 2005-2014: Examination of trends in demographics, length of stay, and cost

Primarily we aimed to examine the crude and standardized schizophrenia hospitalization trend from 2005 to 2014. We hypothesized that there will be a statistically significant linear trend in hospitalization rates for schizophrenia from 2005 to 2014. Secondarily we also examined trends in hospitalization by race/ethnicity, age, gender, as well as trends in hospitalization Length of Stay (LOS) and inflation adjusted cost.In this observational study, we used Nationwide Inpatient Sample data and International Classification of Diseases, Eleventh Revisions codes for Schizophrenia, which revealed 6,122,284 cases for this study. Outcomes included crude and standardized hospitalization rates, race/ethnicity, age, cost, and LOS. The analysis included descriptive statistics, indirect standardization, Rao-Scott Chi-Square test, t-test, and adjusted linear regression trend.Hospitalizations were most prevalent for individuals ages 45-64 (38.8%), African Americans were overrepresented (25.8% of hospitalizations), and the gender distribution was nearly equivalent. Mean LOS was 9.08 days (95% confidence interval 8.71-9.45). Medicare was the primary payer for most hospitalizations (55.4%), with most of the costs ranging from $10,000-$49,999 (57.1%). The crude hospitalization rates ranged from 790-1142/100,000 admissions, while the US 2010 census standardized rates were 380-552/100,000 from 2005-2014. Linear regression trend analysis showed no significant difference in trend for race/ethnicity, age, nor gender (P > .001). The hospitalizations' overall rates increased while LOS significantly decreased, while hospitalization costs and Charlson's co-morbidity index increased (P < .001).From 2005-2014, the overall US hospitalization rates significantly increased. Over this period, observed disparities in hospitalizations for middle-aged and African Americans were unchanged, and LOS has gone down while costs have gone up. Further studies addressing the important disparities in race/ethnicity and age and reducing costs of acute hospitalization are needed.

Gender difference in the association between education and schizophrenia in Chinese adults

BACKGROUND

Improving education level was evidenced to decrease the risk of schizophrenia, but whether this strength of education role depends on gender is not. This study aimed to investigate whether there was gender difference in the association between education and schizophrenia in Chinese adults.

METHODS

Data were obtained from the Second China National Sample Survey on Disability in 2006, including 1,909,205 participants aged 18 years or older. Schizophrenia was ascertained according to the International Statistical Classification of Diseases, Tenth Revision. Logistics regression models were fitted to examine the combined effect of gender and education on schizophrenia.

RESULTS

The lifetime prevalence of schizophrenia in female groups was higher than in male groups, with 0.44% (95%CI: 0.42-0.45%) and 0.36% (95%CI: 0.35-0.37%), respectively. Compared with schizophrenia male patients, more females with schizophrenia experienced severe or extreme difficulty in understanding and communicating. However, more males with schizophrenia suffered from severe or extreme difficulty in the function of daily activities. The combined effect of education and schizophrenia was statistically significant, indicating that, as the level of education increased, schizophrenia risk of females decreased faster than the risk of males.

CONCLUSIONS

This study showed that additional years of education associated with lower risk of schizophrenia, and this association was stronger in females than in males. As education elevated, the risk of schizophrenia decreased more for women than for men. The findings indicate that improving education level may have an effect on reducing the gender disparities in mental health of China. Actions to prevent schizophrenia and address its gender disparities will require attention to the improving educational opportunities.

Association of family history of schizophrenia and history of obstetric complications at birth: relationship with age at onset and psychopathology dimensions in a Nigerian cohort

Background

The nature of the association between obstetric complications (OCs) at birth and the genetic aetiology of schizophrenia remains unclear, as some authors suggest that it is an independent risk factor while others support either interactionism or an epiphenomenon perspective.

Objective

To examine the association of family history of schizophrenia (FHS) with history of OCs, with a view to assessing whether this relationship moderates clinical phenotypes such as symptom dimensions and age at onset of illness.

Methods

This study examined OCs among schizophrenia probands using the Obstetric Complications Scale. An inquiry into family history was performed using the Family history method. Psychopathological symptom dimensions were assessed using standard scales. Data were analyzed to examine the interaction of FHS and history of OCs with age at onset and symptom dimensions, using ANCOVA.

Results

FHS was significantly associated with the disorganized symptoms dimension (p=0.03). History of OCs was significantly associated with earlier age at onset (p=0.007). However, in ANCOVA, the effect of the interaction between FHS and history of OCs was not significant for age at onset and symptom dimensions (P = 0.059).

Conclusion

FHS was significantly associated with disorganization syndrome, and OCs was significantly associated with age at onset.

Polygenetic Risk Scores for Major Psychiatric Disorders Among Schizophrenia Patients, Their First-Degree Relatives, and Healthy Participants

BACKGROUND

The genetic etiology of schizophrenia (SCZ) overlaps with that of other major psychiatric disorders in samples of European ancestry. The present study investigated transethnic polygenetic features shared between Japanese SCZ or their unaffected first-degree relatives and European patients with major psychiatric disorders by conducting polygenic risk score (PRS) analyses.

METHODS

To calculate PRSs for 5 psychiatric disorders (SCZ, bipolar disorder [BIP], major depressive disorder, autism spectrum disorder, and attention-deficit/hyperactivity disorder) and PRSs differentiating SCZ from BIP, we utilized large-scale European genome-wide association study (GWAS) datasets as discovery samples. PRSs derived from these GWASs were calculated for 335 Japanese target participants [SCZ patients, FRs, and healthy controls (HCs)]. We took these PRSs based on GWASs of European psychiatric disorders and investigated their effect on risk in Japanese SCZ patients and unaffected first-degree relatives.

RESULTS

The PRSs obtained from European SCZ and BIP patients were higher in Japanese SCZ patients than in HCs. Furthermore, PRSs differentiating SCZ patients from European BIP patients were higher in Japanese SCZ patients than in HCs. Interestingly, PRSs related to European autism spectrum disorder were lower in Japanese first-degree relatives than in HCs or SCZ patients. The PRSs of autism spectrum disorder were positively correlated with a young onset age of SCZ.

CONCLUSIONS

These findings suggest that polygenic factors related to European SCZ and BIP and the polygenic components differentiating SCZ from BIP can transethnically contribute to SCZ risk in Japanese people. Furthermore, we suggest that reduced levels of an ASD-related genetic factor in unaffected first-degree relatives may help protect against SCZ development.

The CLDN5 locus may be involved in the vulnerability to schizophrenia

The present study was designed to detect three single nucleotide polymorphisms (SNPs) located on 22q11 that was thought as being of particularly importance for genetic research into schizophrenia. We recruited a total of 176 Chinese family trios of Han descent, consisting of mothers, fathers and affected offspring with schizophrenia for the genetic analysis. The transmission disequilibrium test (TDT) showed that of three SNPs, rs10314 in the 3′-untranslated region of the CLDN5 locus was associated with schizophrenia (χ2= 4.75,P= 0.029). The other two SNPs, rs1548359 present in the CDC45L locus centromeric of rs10314 and rs739371 in the 5′-flanking region of the CLDN5 locus, did not show such an association. The global chi-square (χ2) test showed that the 3-SNP haplotype system was not associated with schizophrenia although the 1-df test for individual haplotypes showed that the rs1548359(C)-rs10314(G)-rs739371(C) haplotype was excessively non-transmitted (χ2= 5.32,P= 0.02). Because the claudin proteins are a major component for barrier-forming tight junctions that could play a crucial role in response to changing natural, physiological and pathological conditions, the CLDN5 association with schizophrenia may be an important clue leading to look into a meeting point of genetic and environmental factors.

Analysis of plasma autoantibodies for inflammatory cytokines in patients with first-episode schizophrenia among a Chinese population

Neuroinflammation has been considered to be involved in the development of schizophrenia. This study aimed to study circulating autoantibodies for inflammatory cytokines in first-episode schizophrenia. A total of 181 patients and 197 controls were recruited for detection of plasma IgG antibodies against peptide antigens derived from interleukin 1α (IL1α), IL1ß, IL6, IL8 and tumour necrosis factor alpha (TNFα). The major finding was that patients with schizophrenia had significantly higher levels of anti-IL1ß IgG, anti-IL6 IgG and anti-IL8 IgG, and a significantly lower level of anti-IL1α IgG. This study suggests that inflammatory response may contribute to the development of schizophrenia.

Genetics of schizophrenia in the South African Xhosa

Africa, the ancestral home of all modern humans, is the most informative continent for understanding the human genome and its contribution to complex disease. To better understand the genetics of schizophrenia, we studied the illness in the Xhosa population of South Africa, recruiting 909 cases and 917 age-, gender-, and residence-matched controls. Individuals with schizophrenia were significantly more likely than controls to harbor private, severely damaging mutations in genes that are critical to synaptic function, including neural circuitry mediated by the neurotransmitters glutamine, γ-aminobutyric acid, and dopamine. Schizophrenia is genetically highly heterogeneous, involving severe ultrarare mutations in genes that are critical to synaptic plasticity. The depth of genetic variation in Africa revealed this relationship with a moderate sample size and informed our understanding of the genetics of schizophrenia worldwide.

The influence of defendant race and mental disorder type on mock juror decision-making in insanity trials

This study examined the joint influence of defendant race (Black/White) and mental disorder type (schizophrenia/depression) on mock juror decisions in a Not Guilty by Reason of Insanity (NGRI) case. We reasoned that unwillingness to vote for insanity would be more pronounced for a Black defendant with schizophrenia, given overlapping dangerousness and criminality stereotypes associated with those groups. Online community participants (N = 216) read a fictional second-degree murder case in which we varied mental disorder type and defendant race, then provided a verdict (guilty/NGRI) and answered questions regarding the trial. In line with hypotheses, participants were significantly more likely to vote guilty for a Black defendant with schizophrenia as compared to depression, but there were no significant differences for the White defendant. Results of this study suggest that bias in insanity trials can be exacerbated for a racialized defendant.

Gray matter volume reductions in patients with schizophrenia: A replication study across two cultural backgrounds

Structural gray matter (GM) volume reductions in patients with schizophrenia have rarely been replicated across two different sites, the impact of culture and clinical characteristics remains unresolved. Hence, we assessed GM volume reductions in patients with schizophrenia using 3 T magnetic resonace imaging to replicate results across two independent and culturally different backgrounds (Germany, Japan), and to investigate the impact of brain volume reductions on clinical characteristics. In total, 163 German (80 patients) and 203 Japanese (83 patients) participants were included in the analysis. Voxel-based morphometry (VBM) was used to investigate structural differences between the groups and across the two sites, comparing local GM volumes. Clinical variables were used to analyze effects unrelated to the socio-cultural background. Across both data sets, widespread GM reductions in frontal and temporal cortical parts were found between patients and controls, indicating strong effects of diagnosis and only small effects of site. The investigation of clinical characteristics revealed the strongest effects for chlorpromazine equivalents on GM volume reductions primarily in the Japanese sample. Although the effects of site are small, several brain regions do not overlap between the two groups. Thus, GM may be affected differently at the two sites in patients with schizophrenia.

Risk of schizophrenia, schizoaffective, and bipolar disorders by migrant status, region of origin, and age-at-migration: a national cohort study of 1.8 million people

BACKGROUND

We assessed whether the risk of various psychotic disorders and non-psychotic bipolar disorder (including mania) varied by migrant status, a region of origin, or age-at-migration, hypothesizing that risk would only be elevated for psychotic disorders.

METHODS

We established a prospective cohort of 1 796 257 Swedish residents born between 1982 and 1996, followed from their 15th birthday, or immigration to Sweden after age 15, until diagnosis, emigration, death, or end of 2011. Cox proportional hazards models were used to model hazard ratios by migration-related factors, adjusted for covariates.

RESULTS

All psychotic disorders were elevated among migrants and their children compared with Swedish-born individuals, including schizophrenia and schizoaffective disorder (adjusted hazard ratio [aHR]migrants: 2.20, 95% CI 1.96-2.47; aHRchildren : 2.00, 95% CI 1.79-2.25), affective psychotic disorders (aHRmigrant1.42, 95% CI 1.25-1.63; aHRchildren: 1.22 95% CI 1.07-1.40), and other non-affective psychotic disorders (aHRmigrant: 1.97, 95% CI 1.81-2.14; aHRchildren: 1.68, 95% CI 1.54-1.83). For all psychotic disorders, risks were generally highest in migrants from Africa (i.e. aHRschizophrenia: 5.24, 95% CI 4.26-6.45) and elevated at most ages-of-migration. By contrast, risk of non-psychotic bipolar disorders was lower for migrants (aHR: 0.58, 95% CI 0.52-0.64) overall, and across all ages-of-migration except infancy (aHR: 1.20; 95% CI 1.01-1.42), while risk for their children was similar to the Swedish-born population (aHR: 1.00, 95% CI 0.93-1.08).

CONCLUSIONS

Increased risk of psychiatric disorders associated with migration and minority status may be specific to psychotic disorders, with exact risk dependent on the region of origin.

Schizophrenia Spectrum Disorder Disparity Among African-Americans

Worldwide, Schizophrenia Spectrum Disorder (SSD) affects a low percentage of individuals, but a severe health disparity exists for African-Americans, especially men. Several factors are contributing to this inequality. These factors occur at the individual, social, and organizational levels. With the other challenges facing African-Americans, SSD disparity is another shackle affecting this population. For health care providers, the challenges are treating a complex disorder in a hard to reach and stigmatized population. The purpose of this article is to provide an overview of the SSD disparity among African-Americans as identified in the literature and to discuss the role that Advanced Practice Nurses and other mental health providers have in reducing the disparity.

Bayesian Meta-analysis of Multiple Continuous Treatments with Individual Participant-Level Data: An Application to Antipsychotic Drugs

Modeling dose-response relationships of drugs is essential to understanding their safety effects on patients under realistic circumstances. While intention-to-treat analyses of clinical trials provide the effect of assignment to a particular drug and dose, they do not capture observed exposure after factoring in nonadherence and dropout. We develop a Bayesian method to flexibly model the dose-response relationships of binary outcomes with continuous treatment, permitting multiple evidence sources, treatment effect heterogeneity, and nonlinear dose-response curves. In an application, we examine the risk of excessive weight gain for patients with schizophrenia treated with the second-generation antipsychotics paliperidone, risperidone, or olanzapine in 14 clinical trials. We define exposure as total cumulative dose (daily dose × duration) and convert to units equivalent to 100 mg of olanzapine (OLZ doses). Averaging over the sample population of 5891 subjects, the median dose ranged from 0 (placebo randomized participants) to 6.4 OLZ doses (paliperidone randomized participants). We found paliperidone to be least likely to cause excessive weight gain across a range of doses. Compared with 0 OLZ doses, at 5.0 OLZ doses, olanzapine subjects had a 15.6% (95% credible interval: 6.7, 27.1) excess risk of weight gain; corresponding estimates for paliperidone and risperidone were 3.2% (1.5, 5.2) and 14.9% (0.0, 38.7), respectively. Moreover, compared with nonblack participants, black participants had a 6.8% (1.0, 12.4) greater risk of excessive weight gain at 10.0 OLZ doses of paliperidone. Nevertheless, our findings suggest that paliperidone is safer in terms of weight gain risk than risperidone or olanzapine for all participants at low to moderate cumulative OLZ doses.

Compulsory admission at first presentation to services for psychosis: does ethnicity still matter? Findings from two population-based studies of first episode psychosis

OBJECTIVES

Compared with the majority population, those from minority ethnic groups in the UK are more likely to be admitted compulsorily during a first episode of psychosis (FEP). We investigated whether these disparities in pathways in to care continue.

METHODS

We analysed data from two first episode psychosis studies, conducted in the same geographical area in south London 15 years apart: the Aetiology and Ethnicity in Schizophrenia and Other Psychosis (AESOP) and the Clinical Record Interactive Search-First Episode Psychosis (CRIS-FEP) studies. The inclusion/exclusion criteria for case ascertainment for first episode psychosis were identical across the two studies. We performed multivariable logistic regression to estimate odds of compulsory admission by ethnic group, controlling for confounders.

PARTICIPANTS

Two hundred sixty-six patients with first episode psychosis, aged 18-64 years, who presented to mental health services in south London in 1997-1999 and 446 with FEP who presented in 2010-2012.

RESULTS

When the two samples  were compared, ethnic differences in compulsory admission appear to have remained the same for black African patients, i.e. three times higher than white British in both samples: AESOP (adj. OR = 3.96; 95% CI = 1.80-8.71) vs. CRIS-FEP (adj. OR = 3.12; 95% CI = 1.52-6.35). Black Caribbean patients were three times more likely to be compulsorily admitted in AESOP (adj. OR = 3.20; 95% CI = 1.56-6.54). This was lower in the CRIS-FEP sample (adj. OR = 1.68; 95% CI = 0.71-3.98) and did not meet conventional levels for statistical significance.

CONCLUSION

Ethnicity is strongly associated with compulsory admissions at first presentation for psychosis with evidence of heterogeneity across groups, which deserves further research.

Association between polymorphisms in the GRIN1 gene 5' regulatory region and schizophrenia in a northern Han Chinese population and haplotype effects on protein expression in vitro

BACKGROUND

Schizophrenia is a severe neurodevelopmental disorder with a complex genetic and environmental etiology. Abnormal glutamate ionotropic N-methyl-D-aspartate receptor (NMDA) type subunit 1 (NR1) may be a potential cause of schizophrenia.

METHODS

We conducted a case-control study to investigate the association between the GRIN1 gene, which encodes the NR1 subunit, and the risk of schizophrenia in a northern Chinese Han population using Sanger DNA sequencing. The dual luciferase reporter assay was used to detect the influence of two different haplotypes on GRIN1 gene expression.

RESULTS

Seven SNPs (single nucleotide polymorphisms), including rs112421622 (- 2019 T/C), rs138961287 (- 1962--1961insT), rs117783907 (-1945G/T), rs181682830 (-1934G/A), rs7032504 (-1742C/T), rs144123109 (-1140G/A), and rs11146020 (-855G/C) were detected in the study population. Rs117783907 (-1945G/T) was associated with the occurrence of schizophrenia as a protective factor. The genotype frequencies of rs138961287 (- 1962--1961insT) and rs11146020 (-855G/C) were statistically different between cases and controls (p < 0.0083). The other four variations were not shown to be associated with the disease. Two haplotypes were composed of the seven SNPs, and distribution of T-del-G-G-C-G-G was significantly different between the case and control groups. However, the dual luciferase reporter assay showed that neither of the haplotypes affected luciferase expression in HEK-293 and SK-N-SH cell lines.

CONCLUSIONS

The GRIN1 gene may be related to the occurrence of schizophrenia. Additional research will be needed to fully ascertain the role of GRIN1 in the etiology of schizophrenia.

10-year CVD risk in Han Chinese mainland patients with schizophrenia

People with schizophrenia have a shortened life expectancy, with cardiovascular disease (CVD) being the primary contributor to this excessive mortality. A total of 466 inpatients with schizophrenia and 507 healthy community controls in the Chinese mainland were recruited in this study. Sociodemographic information, medical history, and smoking history were recorded. In addition, total cholesterol (TC), fasting blood glucose (FBG), triglycerides (TG), and high-destiny lipoprotein cholesterol (HDL-C) were analyzed. The 10-year CVD risk was significantly higher in patients with schizophrenia compared with healthy controls. Male schizophrenia patients had significantly higher Framingham risk scores (FRS) than the females. Patients with schizophrenia carried significantly greater risk factors of CVD; body-mass index (BMI), TG and smoking prevalence were significantly higher than in the health community controls, while FBG and HDL-C were on the contrary. Smoking was significantly associated with FRS among schizophrenia inpatients. Collectively, these results suggest that Han Chinese mainland patients with schizophrenia harbor a high 10-year CVD risk when compared with healthy controls, especially in males. CVD in schizophrenia patients requires greater attention by clinicians and researchers.

Navigating Nuances of Language and Meaning: Challenges of Cross-Language Ethnography Involving Shona Speakers Living With Schizophrenia

For people living with schizophrenia, their experience is personal and culturally bound. Focused ethnography enables researchers to understand people's experiences in-context, a prerequisite to providing person-centered care. Data are gathered through observational fieldwork and in-depth interviews with cultural informants. Regardless of the culture, ethnographic research involves resolving issues of language, communication, and meaning. This article discusses the challenges faced by a bilingual, primary mental health nurse researcher when investigating the experiences of people living with schizophrenia in Zimbabwe. Bilingual understanding influenced the research questions, translation of a validated survey instrument and interview transcripts, analysis of the nuances of dialect and local idioms, and confirmation of cultural understanding. When the researcher is a bilingual cultural insider, the insights gained can be more nuanced and culturally enriched. In cross-language research, translation issues are especially challenging when it involves people with a mental illness and requires researcher experience, ethical sensitivity, and cultural awareness.

Schizophrenia in Afro-Caribbean Immigrants

Hospital admission rates for schizophrenia are higher in Afro-Caribbean immigrants to Britain than in the white British-born population. However, the reported differences in incidence and prevalence could be due to confounding variables: the diagnosis of schizophrenia might not carry the same prognostic implications in the two groups; and the differences in formal admission rates might not persist when demographic and diagnostic differences are allowed for. The case-notes of 50 Afro-Caribbean immigrants and 41 British-born white patients with a hospital diagnosis of schizophrenia were examined retrospectively, the average period covered being 12 years. There were no differences in the number of readmissions, but in the Afro-Caribbean group readmissions were shorter. Involuntary admissions were twice as common in Afro-Caribbeans and this excess was not explained by differences in age, sex, or type of illness. The reported excess of schizophrenia in Afro-Caribbean immigrants to Britain is real, but the illness seems to run a milder course than in the white British-born population.

Demographic, psychosocial, clinical, and neurocognitive baseline characteristics of Black Americans in the RAISE-ETP study

This study compared baseline characteristics of Black Americans and Caucasians with first-episode psychosis in the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP). Black American (N=152) and Caucasian (N=218) participants were compared on demographic, psychosocial, clinical, and neurocognitive measures. Results indicated several notable racial differences in baseline characteristics: a greater proportion of Black Americans than Caucasians were female, and Black Americans reported less personal and parental education than Caucasians. Black Americans were also less likely to have private insurance, more likely to be homeless or transient, had significantly poorer quality of life, more severe disorganized symptoms, worse neurocognition, and were less likely to abuse alcohol than Caucasians. The implications of these findings are discussed, and suggestions are provided for future avenues of treatment and research on racial disparities in first-episode psychosis.

Religiosity and religious delusions in schizophrenia - An observational study in a Hindu population

BACKGROUND

Religion exerts a significant effect on the lives of many individuals including people with mental illness. As evidences keep accumulating, role of religion in mental illness is gaining importance.

OBJECTIVES

The study was designed to study the effects of religiosity on religious delusions, its presentation, acute course and outcome in schizophrenia.

METHOD

The study was a naturalistic observational study. Subjects with schizophrenia were grouped into those with religious (RG) and with non-religious delusions (NG). Their premorbid religiosity was assessed with Brief Multi-dimensional measurement of Religiosity/spirituality (BMMRS) and were rated on Scale for Assessment of Positive Symptoms (SAPS), Brown's Assessment of Belief Scale (BABS) and Positive and Negative Symptom Scale (PANSS) at baseline and 4 weeks.

RESULTS

Scores on private religious practices, baseline scores of SAPS, BABS & PANSS and duration of untreated psychosis (DUP) were significantly higher for RG in comparison to NG. On component analysis, higher scores were seen on private praying, watching religious programs on TV, reading religious books and prayers at meals. But no significant correlation was found between the private religious practices and the baseline scores of (DUP), SAPS, BABS, PANSS and outcome measure. Also no significant difference was noted in measures of improvement between groups.

CONCLUSION

Private religious practices are more prominent in patients of schizophrenia with religious delusions and this group of patient seems to present with a more severe illness, and a longer duration of untreated psychosis in comparison to those with non-religious delusions.

Ethnic Minority Status, Age-at-Immigration and Psychosis Risk in Rural Environments: Evidence From the SEPEA Study

OBJECTIVE

Several ethnic minority groups experience elevated rates of first-episode psychosis (FEP), but most studies have been conducted in urban settings. We investigated whether incidence varied by ethnicity, generation status, and age-at-immigration in a diverse, mixed rural, and urban setting.

METHOD

We identified 687 people, 16-35 years, with an ICD-10 diagnosis of FEP, presenting to Early Intervention Psychosis services in the East of England over 2 million person-years. We used multilevel Poisson regression to examine incidence variation by ethnicity, rural-urban setting, generation status, and age-at-immigration, adjusting for several confounders including age, sex, socioeconomic status, population density, and deprivation.

RESULTS

People of black African (incidence rate ratio: 4.06; 95% confidence interval [CI]: 2.63-6.25), black Caribbean (4.63; 95% CI: 2.38-8.98) and Pakistani (2.31; 95% CI: 1.35-3.94) origins were at greatest FEP risk relative to the white British population, after multivariable adjustment. Non-British white migrants were not at increased FEP risk (1.00; 95% CI: 0.77-1.32). These patterns were independently present in rural and urban settings. For first-generation migrants, migration during childhood conferred greatest risk of psychotic disorders (2.20; 95% CI: 1.33-3.62).

CONCLUSIONS

Elevated psychosis risk in several visible minority groups could not be explained by differences in postmigratory socioeconomic disadvantage. These patterns were observed across rural and urban areas of our catchment, suggesting that elevated psychosis risk for some ethnic minority groups is not a result of selection processes influencing rural-urban living. Timing of exposure to migration during childhood, an important social and neurodevelopmental window, may also elevate risk.

Acculturation styles and their associations with psychiatric symptoms and quality of life in ethnic minorities with schizophrenia

This study examined whether Berry's model of acculturative stress would predict psychiatric symptom severity and quality of life (QoL) in ethnic minorities with schizophrenia. Tested extensively in non-psychiatric populations, Berry's framework generally suggests that integration, or engagement with both the host and minority culture, is most adaptive. Using the Abbreviated Multidimensional Acculturation Scale (AMAS), we tested the hypothesis that individuals with schizophrenia who employed an integrative acculturation strategy would have the highest QoL and lowest symptom severity, followed by the assimilation and enculturation groups, then the marginalized group. Psychiatric symptoms and QoL were regressed on AMAS assimilation scores, enculturation scores, and the interaction term in a sample of 128 Hispanic and Blacks with schizophrenia (M age = 41.28; 70% male). Acculturation strategy was not found to relate to psychiatric symptoms (measured from the Brief Psychiatric Rating Scale). However, acculturation strategy did predict QoL (measured from the Quality of Life Inventory), and results were in line with Berry's model. Marginalization may exacerbate issues surrounding social identity in schizophrenia, including low self-concept clarity and internalized stigma. Encouraging bicultural individuals with schizophrenia to interact with the host culture while also practicing traditions from their minority culture may help improve their quality of life.

Examining the impact of migrant status on ethnic differences in mental health service use preceding a first diagnosis of schizophrenia

PURPOSE

Some ethnic groups have more negative contacts with health services for first-episode psychosis, likely arising from a complex interaction between ethnicity, socio-economic factors, and immigration status. Using population-based health administrative data, we sought to examine the effects of ethnic group and migrant status on patterns of health service use preceding a first diagnosis of schizophrenia or schizoaffective disorder among people aged 14-35 over a 10-year period.

METHODS

We compared access to care and intensity of service use for first-generation ethnic minority groups to the general population of Ontario. To control for migrant status, we restricted the sample to first-generation migrants and compared service use indicators for ethnic minority groups to the European migrant group.

RESULTS

Our cohort included 18,080 people with a first diagnosis of schizophrenia or schizoaffective disorder, of whom 14.4% (n = 2607) were the first-generation migrants. Our findings suggest that the magnitude of ethnic differences in health service use is reduced and no longer statistically significant when the sample is restricted to first-generation migrants. Of exception, nearly, all migrant groups have lower intensity of primary care use, and Caribbean migrants are consistently less likely to use psychiatric services.

CONCLUSIONS

We observed fewer ethnic differences in health service use preceding the first diagnosis of psychosis when patterns are compared among first-generation migrants, rather than to the general population, suggesting that the choice of reference group influences ethnic patterning of health service use. We need a comprehensive understanding of the mechanisms behind observed differences for minority groups to adequately address disparities in access to care.

Antipsychotic medications and stroke in schizophrenia: A case-crossover study

BACKGROUND

The association between antipsychotic use and the risk of stroke in schizophrenic patients is controversial. We sought to study the association in a nationwide cohort with schizophrenia.

METHODS

Using a retrospective cohort of patients with schizophrenia (N = 31,976) derived from the Taiwan National Health Insurance Research Database, 802 new-onset cases of stroke were identified within 10 years of follow-up (from 2000 through 2010). We designed a case-crossover study using 14-day windows to explore the risk factors of stroke and the association between antipsychotic drugs and the risk of stroke. We analyzed the risks of individual antipsychotics on various subgroups of stroke including ischemic, hemorrhagic, and other strokes, and the risks based on the antipsychotic receptor-binding profile of each drug.

RESULTS

Use of any second-generation antipsychotic was associated with an increased risk of stroke (adjusted risk ratio = 1.45, P = .009) within 14 days while the use of any first-generation antipsychotic was not. Intriguingly, the use of any second-generation antipsychotic was associated with ischemic stroke but not hemorrhagic stroke. The antipsychotic receptor-binding profile analysis showed that the antihistamine 1 receptor was significantly associated with ischemic stroke (adjusted risk ratio = 1.72, P = .037), and the sensitivity analysis based on the 7-day window of exposure validated the association (adjusted risk ratio = 1.87, P = .015).

CONCLUSIONS

Use of second-generation antipsychotic drugs appeared to be associated with an increased risk of ischemic stroke in the patients studied, possibly mediated by high affinity for histamine-1 receptor blockade. Further research regarding the underlying biological mechanism and drug safety is suggested.

Gender-Specific Associations between CHGB Genetic Variants and Schizophrenia in a Korean Population

PURPOSE

Schizophrenia is a devastating mental disorder and is known to be affected by genetic factors. The chromogranin B (CHGB), a member of the chromogranin gene family, has been proposed as a candidate gene associated with the risk of schizophrenia. The secretory pathway for peptide hormones and neuropeptides in the brain is regulated by chromogranin proteins. The aim of this study was to investigate the potential associations between genetic variants of CHGB and schizophrenia susceptibility.

MATERIALS AND METHODS

In the current study, 15 single nucleotide polymorphisms of CHGB were genotyped in 310 schizophrenia patients and 604 healthy controls.

RESULTS

Statistical analysis revealed that two genetic variants (non-synonymous rs910122; rs2821 in 3'-untranslated region) were associated with schizophrenia [minimum p=0.002; odds ratio (OR)=0.72], even after correction for multiple testing (p(corr)=0.02). Since schizophrenia is known to be differentially expressed between sexes, additional analysis for sex was performed. As a result, these two genetic variants (rs910122 and rs2821) and a haplotype (ht3) showed significant associations with schizophrenia in male subjects (p(corr)=0.02; OR=0.64), whereas the significance disappeared in female subjects (p>0.05).

CONCLUSION

Although this study has limitations including a small number of samples and lack of functional study, our results suggest that genetic variants of CHGB may have sex-specific effects on the risk of schizophrenia and provide useful preliminary information for further study.

Do they see dead people? Cultural factors and sensitivity in screening for schizophrenia spectrum disorders

OBJECTIVE

Schizophrenia spectrum disorders (SSDs), are diagnosed more frequently among African-Americans (AAs) than Caucasians. It has been suggested that cultural differences in symptom presentation and endorsement (including reporting spiritual/religious experiences) may influence this disparity. The current study investigated the relationship between endorsement of spiritual auditory and visual hallucinations and subsequent diagnosis of SSD among AA patients.

DESIGN

Participants (N = 471 AAs) completed the Mini International Neuropsychiatric Interview-Plus (MINI-Plus) Screening Interview as part of their intake to a HIV outpatient clinic. Endorsement of auditory or visual (A/V) hallucinations was explored with the MINI-Plus Psychotic Disorder Module and questions regarding the content of the unusual experience.

RESULTS

Logistic regression indicated that endorsement of A/V hallucinations significantly predicted a SSD (OR = 41.6, 95% CI 13.7-126.0, p < .001). However, when hallucinations were spiritual in nature, odds of an SSD fell dramatically (OR = 0.22, 95% CI 0.07-0.64, p < .001).

CONCLUSIONS

The current study indicates that not all visual and auditory hallucinations are symptomatic of a psychotic disorder in AA patients. Many of these experiences may be related to spirituality. Clinicians assessing AA patients need to query content of, meaning attributed to, and distress associated with A/V unusual experiences.

Association between ErbB4 single nucleotide polymorphisms and susceptibility to schizophrenia: A meta-analysis of case-control studies

BACKGROUND

Accumulating studies have reported inconsistent association between ErbB4 single nucleotide polymorphisms (SNPs) and predisposition to schizophrenia. To better interpret this issue, here we conducted a meta-analysis using published case-control studies.

METHODS

We conducted a systematic search of MEDLINE (Pubmed), Embase (Ovid), Web of Science (Thomson-Reuters) to identify relevant references. The association between ErbB4 SNPs and schizophrenia was assessed by odds ratios (ORs) and 95% confidence intervals (CIs). Between-study heterogeneity was evaluated by I squared (I) statistics and Cochran's Q test. To appraise the stability of results, we employed sensitivity analysis by omitting 1 single study each time. To assess the potential publication bias, we conducted trim and fill analysis.

RESULTS

Seven studies published in English comprising 3162 cases and 4264 controls were included in this meta-analysis. Meta-analyses showed that rs707284 is statistically significantly associated with schizophrenia susceptibility among Asian and Caucasian populations under the allelic model (OR = 0.91, 95% CI: 0.83-0.99, P = 0.035). Additionally, a marginal association (P < 0.1) was observed between rs707284 and schizophrenia risk among Asian and Caucasian populations under the recessive (OR = 0.85, 95% CI: 0.72-1.01, P = 0.065) and homozygous (OR = 0.84, 95% CI: 0.68-1.03, P = 0.094) models. In the Asian subgroup, rs707284 was also noted to be marginally associated with schizophrenia under the recessive model (OR = 0.84, 95% CI: 0.70-1.00, P = 0.053). However, no statistically significant association was found between rs839523, rs7598440, rs3748962, and rs2371276 and schizophrenia risk.

CONCLUSION

This meta-analysis suggested that rs707284 may be a potential ErbB4 SNP associated with susceptibility to schizophrenia. Nevertheless, due to the limited sample size in this meta-analysis, more large-scale association studies are still needed to confirm the results.

The content of delusions in a sample of South African Xhosa people with schizophrenia

BACKGROUND

Although the relationship between cultural beliefs and schizophrenia has received some attention, relatively little work has emerged from African contexts. In this study we draw from a sample of South African Xhosa people with schizophrenia, exploring their cultural beliefs and explanations of illness. The purpose of the article is to examine the relationship between this cultural context and the content of delusions.

METHODS

A sample comprising 200 Xhosa people with schizophrenia participating in a South African schizophrenia genomics study were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Participant delusions were thematically analyzed for recurring themes.

RESULTS

The majority of participants (n = 125 72.5%) believed that others had bewitched them in order to bring about their mental illness, because they were in some way jealous of the participant. This explanation aligns well with the understanding of jealousy-induced witchcraft in Southern African communities and highlights the important role that culture plays in their content of delusions.

CONCLUSIONS

Improved knowledge of these explanatory frameworks highlights the potential value of culturally sensitive assessment tools and stigma interventions in patient recovery. Furthermore such qualitative analyses contribute towards discussion about aspects of delusional thought that may be more universally stable, and those that may be more culturally variable.

Validation of the UCSD Performance-based Skills Assessment (UPSA) in Hispanics with and without schizophrenia

The UCSD Performance-based Skills Assessment (UPSA) is a widely used measure of functional capacity with strong reliability and validity. However there is a lack of psychometric data on Hispanics. The purpose of this study was to determine the impact of acculturation and education on UPSA performance among 62 Hispanic participants with schizophrenia or schizoaffective disorder and 46 healthy comparison subjects. Functional capacity was measured using the UPSA. Acculturation was measured using the Acculturation Rating Scale for Mexican Americans (ARSMA). Independent t-tests indicated that participants with schizophrenia had significantly lower UPSA total scores and scored lower on all UPSA sub-scales relative to the comparison group. Multiple regression also indicated that education and acculturation were significant predictors of UPSA total scores. These data provide a better understanding of UPSA scores in Hispanics with and without schizophrenia, and suggest that education and acculturation adjustments may be required to improve interpretation of test results.

Replication of genome-wide association study (GWAS) susceptibility loci in a Latino bipolar disorder cohort

OBJECTIVES

Recent genome-wide association studies (GWASs) have identified numerous putative genetic polymorphisms associated with bipolar disorder (BD) and/or schizophrenia (SC). We hypothesized that a portion of these polymorphisms would also be associated with BD in the Latino American population. To identify such regions, we tested previously identified genetic variants associated with BD and/or SC and ancestral haploblocks containing these single nucleotide polymorphisms (SNPs) in a sample of Latino subjects with BD.

METHODS

A total of 2254 Latino individuals were genotyped for 91 SNPs identified in previous BD and/or SC GWASs, along with selected SNPs in strong linkage disequilibrium with these markers. Family-based single marker and haplotype association testing was performed using the PBAT software package. Empirical P-values were derived from 10 000 permutations.

RESULTS

Associations of eight a priori GWAS SNPs with BD were replicated with nominal (P≤.05) levels of significance. These included SNPs within nuclear factor I A (NFIA), serologically defined colon cancer antigen 8 (SDCCAG8), lysosomal associated membrane protein 3 (LAMP3), nuclear factor kappa B subunit 1 (NFKB1), major histocompatibility complex, class I, B (HLA-B) and 5'-nucleotidase, cytosolic II (NT5C2) and SNPs within intragenic regions microRNA 6828 (MIR6828)-solute carrier family 7 member 14 (SLC7A14) and sonic hedgehog (SHH)-long intergenic non-protein coding RNA 1006 (LINC01006). Of the 76 ancestral haploblocks that were tested for associations with BD, our top associated haploblock was located in LAMP3; however, the association did not meet statistical thresholds of significance following Bonferroni correction.

CONCLUSIONS

These results indicate that some of the gene variants found to be associated with BD or SC in other populations are also associated with BD risk in Latinos. Variants in six genes and two intragenic regions were associated with BD in our Latino sample and provide additional evidence for overlap in genetic risk between SC and BD.

Genome-wide Analysis of the Role of Copy Number Variation in Schizophrenia Risk in Chinese

BACKGROUND

Compelling evidence suggested the role of copy number variations (CNVs) in schizophrenia susceptibility. Most of the evidence was from studies in populations with European ancestry. We tried to validate the associated CNV loci in a Han Chinese population and identify novel loci conferring risk of schizophrenia.

METHODS

We performed a genome-wide CNV analysis on 6588 patients with schizophrenia and 11,904 control subjects of Han Chinese ancestry.

RESULTS

Our data confirmed increased genome-wide CNV (>500 kb and <1%) burden in schizophrenia, and the increasing trend was more significant when only >1 Mb CNVs were considered. We also replicated several associated loci that were previously identified in European populations, including duplications at 16p11.2, 15q11.2-13.1, 7q11.23, and VIPR2 and deletions at 22q11.2, 1q21.1-q21.2, and NRXN1. In addition, we discovered three additional new potential loci (odds ratio >6, p < .05): duplications at 1p36.32, 10p12.1, and 13q13.3, involving many neurodevelopmental and synaptic related genes.

CONCLUSIONS

Our findings provide further support for the role of CNVs in the etiology of schizophrenia.

Association between PLA2G12A Polymorphisms and Schizophrenia in a Han Chinese Population from Northeast China

Objective

The purpose of this study was to explore the association between single nucleotide polymorphisms (SNPs) in the phospholipase A2 (PLA2), group XIIA gene (PLA2G12A) and schizophrenia.

Methods

This study included 1,063 schizophrenia patients and 1,103 healthy controls from a Han Chinese Population in Northeast China. Four tagSNPs (rs11728699 in intron 1, synonymous rs2285714 in exon 3, rs3087494 in the 3’ UTR, and rs7694620 in the downstream region) in PLA2G12A were selected, and they were genotyped by the MALDI-TOF-MS technology. The Chi-square (χ²) test and haplotype analysis were performed to analyze the association of PLA2G12A SNPs and schizophrenia using the software packages SPSS 16.0 and Haploview 4.2.

Results

Among the four tagSNPs, only SNP rs3087494 in the 3’ UTR of PLA2G12A showed significant differences in both allele frequencies (χ² = 20.136, P<0.001) compared to healthy controls. The minor allele G of SNP rs3087494 is potentially a predictive factor for schizophrenia (OR = 0.753, 95% CI: 0.665–0.882). The frequency distribution of haplotypes consisting of specific alleles of two SNPs (rs7694620-rs3087494 or rs3087494-rs2285714), three SNPs (rs7694620-rs3087494-rs2285714 or rs3087494-rs2285714-rs11728699), or all four SNPs (rs7694620-rs3087494-rs2285714-rs11728699) was significantly different between schizophrenia patients and control subjects (P<0.001).

Conclusions

Our study demonstrated that PLA2G12A SNPs or haplotypes might influence the susceptibility to schizophrenia in the Han Chinese population from Northeast China.

Culture- and Immigration-Related Stress Faced by Chinese American Families with a Patient Having Schizophrenia

The impact of culture and immigration on the experience of Chinese American families with a member having schizophrenia is explored within the frameworks of family systems and stress and coping. This qualitative study was conducted within an intervention study of family psychoeducation using therapists' session notes from 103 family sessions and 13 relatives' group sessions from nine patients and 19 relatives. The high stigma attached to mental illness leading to social isolation, and families' devotion to caregiving exacerbated caregiver burden. Taboo against discussing dating and sexuality and the consideration of arranged marriages caused unique stress. The insecurity as immigrants and shortage of bilingual services were related to greater enmeshment within these families. Implications on research methodology and practice are discussed.

Subjective Experience and Resources for Coping With Stigma in People With a Diagnosis of Schizophrenia: An Intersectional Approach

In this study, we investigate the subjective experience of a group of individuals, diagnosed with schizophrenia, undergoing outpatient treatment in four psychiatric clinics in Mexico City. Our objective is to use the paradigm of intersectionality to explore the most common forms of stigma and discrimination faced by people with this illness, as well as the coping resources they employ. The major contribution of this study is its use of in-depth interviews and thematic analysis of the information obtained to identify the importance of sociocultural aspects of participants' experience of their illness. Schizophrenia, for them, was a problem of "nerves," whose origins were linked to magical or religious elements they attributed to their illness and which influenced their response to it. This resignification was useful to participants as a coping resource; it helped them find meaning and significance in their experience of the illness.

Refugee migration and risk of schizophrenia and other non-affective psychoses: cohort study of 1.3 million people in Sweden

OBJECTIVE

To determine whether refugees are at elevated risk of schizophrenia and other non-affective psychotic disorders, relative to non-refugee migrants from similar regions of origin and the Swedish-born population.

DESIGN

Cohort study of people living in Sweden, born after 1 January 1984 and followed from their 14th birthday or arrival in Sweden, if later, until diagnosis of a non-affective psychotic disorder, emigration, death, or 31 December 2011.

SETTING

Linked Swedish national register data.

PARTICIPANTS

1,347,790 people, including people born in Sweden to two Swedish-born parents (1,191,004; 88.4%), refugees (24,123; 1.8%), and non-refugee migrants (132,663; 9.8%) from four major refugee generating regions: the Middle East and north Africa, sub-Saharan Africa, Asia, and Eastern Europe and Russia.

MAIN OUTCOME MEASURES

Cox regression analysis was used to estimate adjusted hazard ratios for non-affective psychotic disorders by refugee status and region of origin, controlling for age at risk, sex, disposable income, and population density.

RESULTS

3704 cases of non-affective psychotic disorder were identified during 8.9 million person years of follow-up. The crude incidence rate was 38.5 (95% confidence interval 37.2 to 39.9) per 100,000 person years in the Swedish-born population, 80.4 (72.7 to 88.9) per 100,000 person years in non-refugee migrants, and 126.4 (103.1 to 154.8) per 100,000 person years in refugees. Refugees were at increased risk of psychosis compared with both the Swedish-born population (adjusted hazard ratio 2.9, 95% confidence interval 2.3 to 3.6) and non-refugee migrants (1.7, 1.3 to 2.1) after adjustment for confounders. The increased rate in refugees compared with non-refugee migrants was more pronounced in men (likelihood ratio test for interaction χ(2) (df=2) z=13.5; P=0.001) and was present for refugees from all regions except sub-Saharan Africa. Both refugees and non-refugee migrants from sub-Saharan Africa had similarly high rates relative to the Swedish-born population.

CONCLUSIONS

Refugees face an increased risk of schizophrenia and other non-affective psychotic disorders compared with non-refugee migrants from similar regions of origin and the native-born Swedish population. Clinicians and health service planners in refugee receiving countries should be aware of a raised risk of psychosis in addition to other mental and physical health inequalities experienced by refugees.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study

PURPOSE

People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK.

METHODS

E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers.

RESULTS

In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)).

CONCLUSIONS

There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

Comparative study of the efficacy and safety between blonanserin and risperidone for the treatment of schizophrenia in Chinese patients: A double-blind, parallel-group multicenter randomized trial

This randomized, double-blind study compared the efficacy and safety of blonanserin and risperidone to treat Chinese schizophrenia patients aged ≥18 and < 65 years. Patients with Positive and Negative Syndrome Scale (PANSS) total scores ≥70 and ≤ 120 were randomized to receive blonanserin or risperidone using a gradual dose-titration method (blonanserin tablets: 8-24 mg/day; risperidone tablets: 2-6 mg/day), twice daily. Treatment populations consisted of 128 blonanserin-treated patients and 133 risperidone-treated patients. Intention-to-treat analysis was performed using the last observation carried forward method. Reductions of PANSS total scores by blonanserin and risperidone treatment were -30.59 and -33.56, respectively. Risperidone treatment was associated with elevated levels of serum prolactin (67.16% risperidone versus 52.31% blonanserin) and cardiac-related abnormalities (22.39% risperidone versus 12.31% blonanserin), and blonanserin patients were more prone to extrapyramidal side effects (48.46% blonanserin versus 29.10% risperidone). In conclusion, blonanserin was as effective as risperidone for the treatment of Chinese patients with schizophrenia. The overall safety profiles of these drugs are comparable, although blonanserin was associated with a higher incidence of EPS and risperidone was associated with a higher incidence of prolactin elevation and weight gain. Thus, blonanserin is useful for the treatment of Chinese schizophrenia patients.

Cerebral Inefficient Activation in Schizophrenia Patients and Their Unaffected Parents during the N-Back Working Memory Task: A Family fMRI Study

Background

It has been suggested that working memory deficits is a core feature of symptomatology of schizophrenia, which can be detected in patients and their unaffected relatives. The impairment of working memory has been found related to the abnormal activity of human brain regions in many functional magnetic resonance imaging (fMRI) studies. This study investigated how brain region activation was altered in schizophrenia and how it was inherited independently from performance deficits.

Method

The authors used fMRI method during N-back task to assess working memory related cortical activation in four groups (N = 20 in each group, matching task performance, age, gender and education): schizophrenic patients, their unaffected biological parents, young healthy controls for the patients and older healthy controls for their parents.

Results

Compared to healthy controls, patients showed an exaggerated response in the right dorsolateral prefrontal cortex (brodmann area [BA] 46) and bilateral ventrolateral prefrontal cortex, and had reduced activation in bilateral dorsolateral prefrontal cortex (BA 9). In the conjunction analysis, the effect of genetic risk (parents versus older control) shared significantly overlapped activation with effect of disease (patients versus young control) in the right middle frontal gyrus (BA 46) and left inferior parietal gyrus (BA 40).

Conclusions

Physiological inefficiency of dorsal prefrontal cortex and compensation involvement of ventral prefrontal cortex in working memory function may one physiological characteristics of schizophrenia. And relatively inefficient activation in dorsolateral prefrontal cortex probably can be a promising intermediate phenotype for schizophrenia.

Association Study of N-Methyl-D-Aspartate Receptor Subunit 2B (GRIN2B) Polymorphisms and Schizophrenia Symptoms in the Han Chinese Population

Schizophrenia (SZ) is a common and complex psychiatric disorder that has a significant genetic component. The glutamatergic system is the major excitatory neurotransmitter system in the central nervous system, and is mediated by N-methyl-D-aspartate (NMDA) receptors. Disturbances in this system have been hypothesized to play a major role in SZ pathogenesis. Several studies have revealed that the NMDA receptor subunit 2B (GRIN2B) potentially associates with SZ and its psychiatric symptoms. In this study, we performed a case–control study to identify polymorphisms of the GRIN2B gene that may confer susceptibility to SZ in the Han Chinese population. Thirty-four single nucleotide polymorphisms (SNPs) were genotyped in 528 paranoid SZ patients and 528 control subjects. A significant association was observed in allele and genotype between SZ and controls at rs2098469 (χ² = 8.425 and 4.994; p = 0.025 and 0.014, respectively). Significant associations were found in the allele at rs12319804 (χ² = 4.436; p = 0.035), as well as in the genotype at rs12820037 and rs7298664 between SZ and controls (χ² = 11.162 and 38.204; p = 0.003 and 4.27×10^-8, respectively). After applying the Bonferroni correction, rs7298664 still had significant genotype associations with SZ (p = 1.71×10^-7). In addition, rs2098469 genotype and allele frequencies, and 12820037 allele frequencies were nominally associated with SZ. Three haplotypes, CGA (rs10845849—rs12319804—rs10845851), CC (rs12582848—rs7952915), and AAGAC (rs2041986—rs11055665—rs7314376—rs7297101—rs2098469), had significant differences between SZ and controls (χ² = 4.324, 4.582, and 4.492; p = 0.037, 0.032, and 0.034, respectively). In addition, three SNPs, rs2098469, rs12820037, and rs7298664, were significantly associated with cognition factors PANSS subscores in SZ (F = 16.799, 7.112, and 13.357; p = 0.000, 0.017, and 0.000, respectively). In conclusion, our study provides novel evidence for an association between GRIN2B polymorphisms and SZ susceptibility and symptoms in the Han Chinese population.

Validation of the German Version of the Social Functioning Scale (SFS) for schizophrenia

Deficits in social functioning are a core symptom of schizophrenia and an important criterion for evaluating the success of treatment. However, there is little agreement regarding its measurement. A common, often cited instrument for assessing self-reported social functioning is the Social Functioning Scale (SFS). The study aimed to investigate the reliability and validity of the German translation. 101 patients suffering from schizophrenia (SZ) and 101 matched controls (C) (60 male / 41 female, 35.8 years in both groups) completed the German version. In addition, demographic, clinical, and functional data were collected. Internal consistency was investigated calculating Cronbach's alpha for SFS full scale (α: .81) and all subscales (α: .59-.88). Significant bivariate correlation coefficients were found between all subscales as well as between all subscales and full scale (p <.01). For the total sample, principal component analysis gave evidence to prefer a single-factor solution (eigenvalue ≥ 1) accounting for 48.5 % of the variance. For the subsamples, a two-component solution (SZ; 57.0 %) and a three-component solution (C; 65.6 %) fitted best, respectively. For SZ and C, significant associations were found between SFS and external criteria. The main factor "group" emerged as being significant. C showed higher values on both subscales and full scale. The sensitivity of the SFS was examined using discriminant analysis. 86.5% of the participants could be categorized correctly to their actual group. The German translation of the SFS turned out to be a reliable and valid questionnaire comparable to the original English version. This is in line with Spanish and Norwegian translations of the SFS. Concluding, the German version of the SFS is well suited to become a useful and practicable instrument for the assessment of social functioning in both clinical practice and research. It accomplishes commonly used external assessment scales.

Comparing schizophrenia symptoms in the Iban of Sarawak with other populations to elucidate clinical heterogeneity

INTRODUCTION

The symptom profile of schizophrenia can vary between ethnic groups. We explored selected symptom variables previously reported to be characteristic of schizophrenia in the Iban of Sarawak in transethnic populations from Australia, India, and Sarawak, Malaysia. We tested site differences to confirm previous research, and to explore implications of differences across populations for future investigations.

METHODS

We recruited schizophrenia samples in Australia (n = 609), India (n = 310) and Sarawak (n = 205) primarily for the purposes of genetic studies. We analyzed seven identified variables and their relationship to site using logistic regression, including: global delusions, bizarre delusions, thought broadcast/insertion/withdrawal delusions, global hallucinations, auditory hallucinations, disorganized behavior, and prodromal duration.

RESULTS

We identified a distinct symptom profile in our Sarawak sample. Specifically, the Iban exhibit: low frequency of thought broadcast/insertion/withdrawal delusions, high frequency of auditory hallucinations and disorganized behavior, with a comparatively short prodrome when compared with Australian and Indian populations.

DISCUSSION

Understanding between-site variation in symptom profile may complement future transethnic genetic studies, and provide important clues as to the nature of differing schizophrenia expression across ethnically distinct groups. A comprehensive approach to subtyping schizophrenia is warranted, utilizing comprehensively ascertained transethnic samples to inform both schizophrenia genetics and nosology.

Genetic association of LMAN2L gene in schizophrenia and bipolar disorder and its interaction with ANK3 gene polymorphism

Recent studies have shown that bipolar disorder (BPD) and schizophrenia (SZ) share some common genetic risk factors. This study aimed to examine the association between candidate single nucleotide polymorphisms (SNPs) identified from genome-wide association studies (GWAS) and risk of BPD and SZ. A total of 715 patients (244 BPD and 471 SZ) and 593 controls were genotyped using the Sequenom MassARRAY platform. We showed a positive association between LMAN2L (rs6746896) and risk of both BPD and SZ in a pooled population (P-value=0.001 and 0.009, respectively). Following stratification by ethnicity, variants of the ANK3 gene (rs1938516 and rs10994336) were found to be associated with BPD in Malays (P-value=0.001 and 0.006, respectively). Furthermore, an association exists between another variant of LMAN2L (rs2271893) and SZ in the Malay and Indian ethnic groups (P-value=0.003 and 0.002, respectively). Gene-gene interaction analysis revealed a significant interaction between the ANK3 and LMAN2L genes (empirical P=0.0107). Significant differences were shown between patients and controls for two haplotype frequencies of LMAN2L: GA (P=0.015 and P=0.010, for BPD and SZ, respectively) and GG (P=0.013 for BPD). Our study showed a significant association between LMAN2L and risk of both BPD and SZ.

DSM-IV "criterion A" schizophrenia symptoms across ethnically different populations: evidence for differing psychotic symptom content or structural organization?

There is significant variation in the expression of schizophrenia across ethnically different populations, and the optimal structural and diagnostic representation of schizophrenia are contested. We contrasted both lifetime frequencies of DSM-IV criterion A (the core symptom criterion of the internationally recognized DSM classification system) symptoms and types/content of delusions and hallucinations in transethnic schizophrenia populations from Australia (n = 776), India (n = 504) and Sarawak, Malaysia (n = 259), to elucidate clinical heterogeneity. Differences in both criterion A symptom composition and symptom content were apparent. Indian individuals with schizophrenia reported negative symptoms more frequently than other sites, whereas individuals from Sarawak reported disorganized symptoms more frequently. Delusions of control and thought broadcast, insertion, or withdrawal were less frequent in Sarawak than Australia. Curiously, a subgroup of 20 Indian individuals with schizophrenia reported no lifetime delusions or hallucinations. These findings potentially challenge the long-held view in psychiatry that schizophrenia is fundamentally similar across cultural groups, with differences in only the content of psychotic symptoms, but equivalence in structural form.

Long-term outcome of schizoaffective disorder. Are there any differences with respect to schizophrenia?

BACKGROUND

A number of studies suggest that the clinical characteristics and long-term outcome of schizoaffective patients closely resemble those observed in schizophrenia when cases are diagnosed according to DSM criteria. The primary aim was to compare remission and recovery rates in a cohort of chronic schizoaffective and schizophrenic outpatients.

METHODS

A sample of 102 consecutive outpatients, 46 affected by schizophrenia (45.1%, mean age 44.22±9.97 years) and 66 affected by schizoaffective disorder (54.9%, mean age 43.00±9.07 years) was examined in the study. Personal data and psychiatric history were collected according to AMDP system; premorbid assessment was performed by means of PAS. Axis I and II psychiatric diagnosis was confirmed by means of SCID-I and II. Psychopathological status was evaluated by means of PANSS and CGI-SCH scales; neuropsychological evaluation was performed by means of BACS and MMSE; Functioning, subjective well-being and quality of life were respectively evaluated by means of PSP, SWN and WHOQoL-bref.

RESULTS

Schizophrenic and schizoaffective patients investigated were characterized by an overlapping age at onset, mean duration of illness, mean duration of untreated psychosis and common sociodemographic characteristics; subjects' cross-sectional psychopathological and neurocognitive profiles were remarkably similar. However, schizoaffective patients are more frequently of the female gender, showing a better social premorbid adjustment and a somewhat more complicated clinical course in terms of more frequent hospitalizations and suicidality; outcome measures are substantially better among schizoaffective patients: rates of clinical remission were 43.5% and 54.5% in schizophrenic and schizoaffective patients, respectively; 13% and 25.8% of schizophrenic and schizoaffective patients, respectively, were considered as functionally remitted; recovery was observed in 6.5% and 22.7% of schizophrenic and schizoaffective patients, respectively; the majority of patients, both schizophrenic and schizoaffective, were taking antipsychotics, mainly atypical, although a significantly higher proportion of schizoaffective subjects were on mood stabilizers, antidepressants and benzodiazepines.

CONCLUSION

Compared to schizophrenic patients, DSM-IV-TR schizoaffective patients may be considered as a subgroup of psychotic patients displaying several specific characteristics in terms of clinical course, clinical and functional outcome and treatment.