Neighborhood-level predictors of age at onset and duration of untreated psychosis in first-episode psychotic disorders
Introduction
Neighborhood characteristics are known to be important social determinants of health, influencing a wide range of outcomes related to chronic physical illnesses such as obesity and diabetes (Ludwig et al., 2011). Growing evidence suggests that neighborhood characteristics influence the rates and outcomes of mental illnesses as well, including schizophrenia (Eaton et al., 2019; Heinz et al., 2013; Kirkbride et al., 2014). Though sparsely studied in the United States, this association was first explored >80 years ago when Faris and Dunham (1939) demonstrated an association between high rates of schizophrenia and city zones in Chicago characterized by social disorder or lack of cohesion. They argued that those who resided in disorganized communities found it difficult to foster and maintain positive affiliations with local institutions, neighbors, and family members, thus increasing these residents' sense of social isolation, which was deemed significant to the onset and course of mental illnesses (Faris and Dunham, 1939). Some recent research suggests that neighborhood characteristics may influence rates of schizophrenia. Specifically, more population-dense areas and areas with lower socioeconomic status may have higher incidence rates of psychosis (Heinz et al., 2013; Kirkbride et al., 2014; Richardson et al., 2018). In addition, a few studies have assessed neighborhood variation in relation to prognostic factors and positive symptoms (Kirkbride et al., 2010; Newbury et al., 2016). However, in the United States, there has been a dearth of research to characterize the relationship between specific neighborhood factors and key manifestations of schizophrenia and related psychotic disorders.
An earlier age at onset of psychosis (AOP) and longer duration of untreated psychosis (DUP) are two important factors associated with poorer prognosis for schizophrenia (e.g., greater symptom severity, longer time to and less likelihood of remission). Known risk factors for earlier AOP, one of the most commonly examined predictors of outcomes in schizophrenia (Clemmensen et al., 2012; Hafner et al., 1998; Immonen et al., 2017), include family history of psychosis (Suvisaari et al., 1998), male gender (Gureje, 1991; Hafner et al., 1998), and earlier age at initiation and more rapid escalation of premorbid cannabis use (Arseneault et al., 2002; Compton et al., 2009b; Kelley et al., 2016; McGrath et al., 2010; Stefanis et al., 2013; Zammit et al., 2002). Longer DUP is associated with poorer response to treatment, more frequent relapses, and poorer long-term symptom and functioning outcomes (Marshall et al., 2005; Perkins et al., 2005). Conversely, early detection of and intervention for psychosis considerably improves outcomes (Burns, 2013). Risk factors for longer DUP include chronic or insidious mode of onset of psychosis (Compton et al., 2008; Larsen et al., 1996; Morgan et al., 2006), history of incarceration (Broussard et al., 2013), and possibly cannabis use (Broussard et al., 2013; Burns, 2012).
Given the significance of AOP and DUP to the prognosis of schizophrenia, identifying other modifiable risk factors shaping them could ultimately inform means of improving outcomes. Exploring whether neighborhood characteristics in adolescence affect AOP and DUP could have a public health impact by leading to population-level interventions to influence the rate and course of psychotic disorders (and at the same time, many other illnesses and health outcomes).
To further explore the relationship between neighborhood characteristics and prognostic factors in early-course psychotic disorders, this analysis investigated the following questions: (1) Which neighborhood-level characteristics (both subjectively rated and objectively obtained), if any, are associated with AOP and DUP? (2) Do any potential effects of neighborhood-level characteristics on these prognostic factors remain after controlling for known risk factors for AOP and DUP? (3) Do the potential effects of neighborhood-level characteristics on these prognostic factors remain after controlling for individual-level sociodemographic characteristics? This study builds on the well-established link of urbanicity and neighborhood adversity with psychosis by examining the association of several neighborhood characteristics with AOP and DUP.
There have only been two studies investigating the relationship between neighborhood characteristics and DUP, in Southeast London and South Dublin (Kirkbride et al., 2010; O'Donoghue et al., 2016), which found conflicting results. While one study did not find variability in DUP across neighborhoods in Southeast London (Kirkbride et al., 2010), another reported that the least socially fragmented neighborhoods in South Dublin had very short DUPs (O'Donoghue et al., 2016). This is the first study in the United States, to our knowledge, to study the relationship between neighborhood characteristics and two prognostic factors: AOP and DUP. As such, we made no a priori hypotheses regarding the relationships between specific neighborhood characteristics and AOP or DUP. Based on prior literature examining the relationship between neighborhood characteristics and other health outcomes in the United States (Alegría et al., 2014; Krieger et al., 2002; Silver et al., 2002), we employed both objective (i.e., those obtained from census-tract data) and subjective (based on self-reported perceptions) measures of neighborhood characteristics to explore possible associations with AOP and DUP.
Section snippets
Subjects
The data were part of a project designed primarily to investigate the associations between premorbid cannabis use and AOP. This project included patients admitted to the hospital for a first episode of a schizophrenia-spectrum disorder; they were referred by clinicians in three inpatient psychiatric units in Atlanta, Georgia and three in Washington, D.C., based on the clinical diagnosis. The eligible age range for the study was 18 to 30 years. The Structured Clinical Interview for DSM-IV Axis I
Sample characteristics
SCID-determined diagnoses among the 143 participants included: schizophrenia (78, 54.6%), schizophreniform disorder (21, 14.7%), psychotic disorder not otherwise specified (25, 17.5%), schizoaffective disorder (14, 9.8%), delusional disorder (3, 2.1%), and brief psychotic disorder (2, 1.4%). The median age of participants was 22 years. The median years of school completed was 12. Most participants were African American (86.0%). The percentage of participants with a history of cannabis use was
Discussion
This study found that neighborhood-level characteristics affect important prognostic factors in early psychosis, specifically AOP and DUP. Even when controlling for known predictors of earlier AOP—and when controlling for individual-level residential instability—greater census-tract-level residential instability was associated with an earlier AOP. We also found that perceived/subjective neighborhood disorder as measured by the NDS was associated with a longer DUP and census-tract-level
Contributors
BK, LP, MM, and MC designed the study, wrote the protocol, conducted literature review and data analyses. BK, LP, and MC conducted data collection. BK wrote the first draft of the manuscript. LP, MM and MC gave substantial comments and edited the manuscript. All authors contributed to the manuscript and approved the final manuscript.
Funding
This research was supported by grants K23 MH067589 and R01 MH081011 from the National Institute of Mental Health (NIMH).
Declaration of competing interest
The authors have declared that there are no conflicts of interest in relation to the subject of this study.
Acknowledgement
None.
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2022, Health and PlaceCitation Excerpt :Among such factors shown to positively affect the well-being of those living with schizophrenia are: degrees of privacy; comfort and calmness; sense of security; and access to amenities (Piat et al., 2017); and the presence of affordances for social interactions and the management of diverse affective states (Brewster, 2014; Doroud et al., 2018; Duff, 2012; Söderström et al., 2017). Factors that appear to heighten risk include crowding (Söderström et al., 2016) and neighbourhood instability, whether captured in housing data (e.g., frequent changes in dwelling) (Ku et al., 2020), rates of owner-occupied housing (Jongsma et al., 2018), assessments of a resident's perceived link to place (e.g., feeling unwelcome in, pushed out, or not fitting into one's neighbourhood) (Narita et al., 2020), measures of neighbourhood disorder (Ku et al., 2020), or, as mentioned above, stresses associated with a fear or experience of crime and violence. Researchers influenced by the work of Wilbert Gesler on therapeutic landscapes have studied how three overlapping dimensions—physical, social, and symbolic—interact to create environments conducive to healing processes.
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2022, Behavioural Brain ResearchCitation Excerpt :High levels of social cohesion, the counter to social fragmentation, were linked to reduced psychosis risk [40]. In a recent original study, residential instability predicted earlier age of psychosis onset after controlling for family history of schizophrenia, male gender, and age at first cannabis use [130]. A UK study found a relationship between urban upbringing and psychotic experiences among adolescents after controlling for family SES, family psychiatric history, maternal psychosis, adolescent substance use, and neighborhood deprivation.