The incidence of psychoses in diverse settings, INTREPID (2): a feasibility study in India, Nigeria, and Trinidad.

BACKGROUND: There are striking global inequities in our knowledge of the incidence, aetiology, and outcome of psychotic disorders. For example, only around 10% of research on incidence of psychotic disorders originates in low- and middle-income countries. We established INTREPID I to develop, implement, and evaluate, in sites in India (Chengalpet), Nigeria (Ibadan), and Trinidad (Tunapuna-Piarco), methods for identifying and recruiting untreated cases of psychosis, as a basis for investigating incidence and, subsequently, risk factors, phenomenology, and outcome. In this paper, we compare case characteristics and incidence rates across the sites. METHOD: In each site, to identify untreated cases of psychoses in defined catchment areas, we established case detection systems comprising mental health services, traditional and spiritual healers, and key informants. RESULTS: Rates of all untreated psychoses were 45.9 (per 1 00 000 person-years) in Chengalpet, 31.2 in Ibadan, and 36.9 in Tunapuna-Piarco. Duration of psychosis prior to detection was substantially longer in Chengalpet (median 232 weeks) than in Ibadan (median 13 weeks) and Tunapuna-Piarco (median 38 weeks). When analyses were restricted to cases with a short duration (i.e. onset within preceding 2 years) only, rates were 15.5 in Chengalpet, 29.1 in Ibadan, and 26.5 in Tunapuna-Piarco. Further, there was evidence of age and sex differences across sites, with an older average age of onset in Chengalpet and higher rates among women in Ibadan. CONCLUSION: Our findings suggest there may be differences in rates of psychoses and in the clinical and demographic profiles of cases across economically and socially distinct settings.

What determines continuing grey matter changes in first-episode schizophrenia and affective psychosis?

BACKGROUND: Magnetic resonance imaging (MRI) studies have shown that brain abnormalities in psychosis might be progressive during the first years of illness. We sought to determine whether first-episode psychosis (FEP) subjects show progressive regional grey matter (GM) changes compared with controls, and whether those changes are associated with diagnosis, illness course or antipsychotic (AP) use. METHOD: Thirty-two subjects with first-episode schizophrenia-spectrum disorders (FESZ), 24 patients with first-episode affective psychoses (FEAP) and 34 controls recruited using a population-based design underwent structural MRI scanning at baseline and at a 5-year follow-up. Regional GM volumes were assessed with voxel-based morphometry (VBM). Patients were treated at community settings, and about half of them remained mainly untreated. RESULTS: No significant progressive changes in GM regional volumes were observed in either the FESZ or FEAP group overall. However, FESZ subjects with a non-remitting course showed GM decrements in the left superior temporal gyrus (STG) and insula relative to remitted FESZ subjects. Non-remitted FEAP subjects exhibited a GM decrease in the dorsolateral prefrontal cortex (DLPFC) bilaterally in comparison to remitted FEAP subjects. Among FESZ subjects, AP use was associated with regional GM decrements in the right insula and increments in the cerebellum. CONCLUSIONS: Our results suggest that the progression of brain abnormalities in FEP subjects is restricted to those with a poor outcome and differs between diagnosis subgroups. AP intake is associated with a different pattern of GM reductions over time.

New vanadium compounds in Venezuela heavy crude oil detected by positive-ion electrospray ionization fourier transform ion cyclotron resonance mass spectrometry.

Metalloporphyrins are ubiquitous in nature, particularly iron porphyrins (hemes) and magnesium dihydroporphyrins or chlorophylls. Oxovanadium (IV) complexes of alkyl porphyrins are widely distributed in petroleum, oil shales and maturing sedimentary bitumen. Here we identify new vanadium compounds in Venezuela Orinoco heavy crude oil detected by Fourier transform-ion cyclotron resonance mass spectrometry (FT-ICR MS). These compounds likely have the main structure of porphyrin, with the addition of more aromatic rings, thiophene and amino functional groups, corresponding to molecular series of C(n)H(2n-40)N(4)V(1)O(1) (36 ≤ n ≤ 58),C(n)H(2n-42)N(4)V(1)O(1) (37 ≤ n ≤ 57),C(n)H(2n-44)N(4)V(1)O(1) (38 ≤ n ≤ 59),C(n)H(2n-46)N(4)V(1)O(1) (43 ≤ n ≤ 54),C(n)H(2n-48)N(4)V(1)O(1) (45 ≤ n ≤ 55),C(n)H(2n-38)N(4)V(1)S(1)O(1) (36 ≤ n ≤ 41),C(n)H(2n-40)N(4)V(1)S(1)O(1) (35 ≤ n ≤ 51),C(n)H(2n-42)N(4)V(1)S(1)O(1) (36 ≤ n ≤ 54),C(n)H(2n-44)N(4)V(1)S(1)O(1) (41 ≤ n ≤ 55),C(n)H(2n-46)N(4)V(1)S(1)O(1) (39 ≤ n ≤ 55),C(n)H(2n-27)N(5)V(1)O(1) (29 ≤ n ≤ 40),C(n)H(2n-29)N(5)V(1)O(1) (34 ≤ n ≤ 42),C(n)H(2n-33)N(5)V(1)O(1) (31 ≤ n ≤ 38),C(n)H(2n-35)N(5)V(1)O(1) (32 ≤ n ≤ 41),C(n)H(2n-27)N(5)V(1)O(2) (32 ≤ n ≤ 41) and C(n)H(2n-29)N(5)V(1)O(2) (33 ≤ n ≤ 42). These findings are significant for the understanding of the existing form of vanadium species in nature, and are helpful for enhancing the amount of information on palaeoenvironments and improving the level of applied basic theory for the processing technologies of heavy oils.

Longitudinal follow-up of cavum septum pellucidum and adhesio interthalamica alterations in first-episode psychosis: a population-based MRI study.

BACKGROUND: Neurodevelopmental alterations have been described inconsistently in psychosis probably because of lack of standardization among studies. The aim of this study was to conduct the first longitudinal and population-based magnetic resonance imaging (MRI) evaluation of the presence and size of the cavum septum pellucidum (CSP) and adhesio interthalamica (AI) in a large sample of patients with first-episode psychosis (FEP). METHOD: FEP patients (n=122) were subdivided into schizophrenia (n=62), mood disorders (n=46) and other psychosis (n=14) groups and compared to 94 healthy next-door neighbour controls. After 13 months, 80 FEP patients and 52 controls underwent a second MRI examination. RESULTS: We found significant reductions in the AI length in schizophrenia FEP in comparison with the mood disorders and control subgroups (longer length) at the baseline assessment, and no differences in any measure of the CSP. By contrast, there was a diagnosis×time interaction for the CSP length, with a more prominent increase for this measure in the psychosis group. There was an involution of the AI length over time for all groups but no diagnosis×time interaction. CONCLUSIONS: Our findings suggest that the CSP per se may not be linked to the neurobiology of emerging psychotic disorders, although it might be related to the progression of the disease. However, the fact that the AI length was shown to be shorter at the onset of the disorder supports the neurodevelopmental model of schizophrenia and indicates that an alteration in this grey matter junction may be a risk factor for developing psychosis.

Lack of progression of brain abnormalities in first-episode psychosis: a longitudinal magnetic resonance imaging study.

BACKGROUND: Some neuroimaging studies have supported the hypothesis of progressive brain changes after a first episode of psychosis. We aimed to determine whether (i) first-episode psychosis patients would exhibit more pronounced brain volumetric changes than controls over time and (ii) illness course/treatment would relate to those changes. METHOD: Longitudinal regional grey matter volume and ventricle:brain ratio differences between 39 patients with first-episode psychosis (including schizophrenia and schizophreniform disorder) and 52 non-psychotic controls enrolled in a population-based case-control study. RESULTS: While there was no longitudinal difference in ventricle:brain ratios between first-episode psychosis subjects and controls, patients exhibited grey matter volume changes, indicating a reversible course in the superior temporal cortex and hippocampus compared with controls. A remitting course was related to reversal of baseline temporal grey matter deficits. CONCLUSIONS: Our findings do not support the hypothesis of brain changes indicating a progressive course in the initial phase of psychosis. Rather, some brain volume abnormalities may be reversible, possibly associated with a better illness course.

Differing patterns of brain structural abnormalities between black and white patients with their first episode of psychosis

BACKGROUND: African-Caribbean and black African people living in the UK are reported to have a higher incidence of diagnosed psychosis compared with white British people. It has been argued that this may be a consequence of misdiagnosis. If this is true they might be less likely to show the patterns of structural brain abnormalities reported in white British patients. The aim of this study therefore was to investigate whether there are differences in the prevalence of structural brain abnormalities in white and black first-episode psychosis patients. METHOD: We obtained dual-echo (proton density/T2-weighted) images from a sample of 75 first-episode psychosis patients and 68 healthy controls. We used high resolution magnetic resonance imaging and voxel-based methods of image analysis. Two separate analyses were conducted: (1) 34 white British patients were compared with 33 white British controls; (2) 41 African-Caribbean and black African patients were compared with 35 African-Caribbean and black African controls. RESULTS: White British patients and African-Caribbean/black African patients had ventricular enlargement and increased lenticular nucleus volume compared with their respective ethnic controls. The African-Caribbean/black African patients also showed reduced global grey matter and increased lingual gyrus grey-matter volume. The white British patients had no regional or global grey-matter loss compared with their normal ethnic counterparts but showed increased grey matter in the left superior temporal lobe and right parahippocampal gyrus. CONCLUSIONS: We found no evidence in support of our hypothesis. Indeed, the finding of reduced global grey-matter volume in the African-Caribbean/black African patients but not in the white British patients was contrary to our prediction.

Grey matter correlates of minor physical anomalies in the AESOP first-episode psychosis study

BACKGROUND: Minor physical anomaliesare more prevalent among people withpsychosis. This supports aneurodevelopmental aetiology forpsychotic disorders, since these anomalies and the brain are both ectodermally derived. However, little is understood about the brain regions implicated in this association. AIMS: To examine the relationship between minor physical anomalies and grey matter structure in a sample of patients with first-episode psychosis. METHOD: Sixty patients underwent assessment of minor physical anomalies with the Lane scale. High-resolution magnetic resonance images and voxel-based methods of image analysis were used to investigate brain structure in these patients. RESULTS: The total anomalies score was associated with a grey matter reduction in the prefrontal cortex and precuneus and with a grey matter excess in the basal ganglia, thalamus and lingual gyrus. CONCLUSIONS: Minor physical anomalies in a sample of patients with first-episode psychosis are associated with regionalgrey matter changes. These regional changes may be important in the pathogenesis of psychotic disorder.

Pathways to care and ethnicity. 1: Sample characteristics and compulsory admission. Report from the AESOP study.

BACKGROUND: Many studies have found high levels of compulsory admission to psychiatric hospital in the UK among African-Caribbean and Black African patients with a psychotic illness. AIMS: To establish whether African-Caribbean and Black African ethnicity is associated with compulsory admission in an epidemiological sample of patients with a first episode of psychosis drawn from two UK centres. METHOD: All patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas were included in the (AESOP) study. For this analysis we included all White British, other White, African-Caribbean and Black African patients from the AESOP sampling frame. Clinical, socio-demographic and pathways to care data were collected from patients, relatives and case notes. RESULTS: African-Caribbean patients were significantly more likely to be compulsorily admitted than White British patients, as were Black African patients. African-Caribbean men were the most likely to be compulsorily admitted. CONCLUSIONS: These findings suggest that factors are operating at or prior to first presentation to increase the risk of compulsory admission among African-Caribbean and Black African patients.

Pathways to care and ethnicity. 2: Source of referral and help-seeking. Report from the AESOP study.

BACKGROUND: Previous research has found that African-Caribbean and Black African patients are likely to come into contact with mental health services via more negative routes, when compared with White patients. We sought to investigate pathways to mental health care and ethnicity in a sample of patients with a first episode of psychosis drawn from two UK centres. METHOD: We included all White British, other White, African-Caribbean and Black African patients with a first episode of psychosis who made contact with psychiatric services over a 2-year period and were living in defined areas. Clinical, socio-demographic and pathways to care data were collected from patients, relatives and case notes. RESULTS: Compared with White British patients, general practitioner referral was less frequent for both African-Caribbean and Black African patients and referral by a criminal justice agency was more common. With the exception of criminal justice referrals for Black African patients, these findings remained significant after adjusting for potential confounders. CONCLUSIONS: These findings suggest that factors are operating during a first episode of psychosis to increase the risk that the pathway to care for Black patients will involve non-health professionals.

Pregnancy and birth complications in patients with schizophrenia in Trinidad and London.

It has been shown that an excess of pregnancy and birth complications (PBCs) does not contribute to the excess rates of schizophrenia reported for the population of Caribbean origin in Britain compared with the native Caucasian British population. We therefore attempted to compare the rate of PBCs between a sample of schizophrenics in Britain with that of a sample from Trinidad where some of the Caribbean migrants to Britain originated. First contact patients with schizophrenia according to the CATEGO system diagnosis were identified in Trinidad and London. Their mothers, where available, were interviewed using the Lewis-Murray scale for pregnancy and birth complications. Data from Trinidad and Tobago concerning 56 patients were compared with those of the Caucasian (n = 61) and African-Caribbean (n = 50) patients in London. The rate of PBCs was similar for the Caucasian British patients (24.6%) and the patients in Trinidad and Tobago (21.7%). The rates were lowest in the African-Caribbean patients in London (14.0%), though this difference was not statistically significant. These findings suggest that pregnancy and birth complications are a risk factor for a substantial minority of patients with schizophrenia in Trinidad and London. It also confirms that the excess rates of schizophrenia reported for the Caribbean population in Britain are not due to these complications.

Understanding the excess of psychosis among the African-Caribbean population in England. Review of current hypotheses.

BACKGROUND: Increased rates of schizophrenia continue to be reported among the African-Caribbean population in England. AIMS: To evaluate the competing biological, psychological and social explanations that have been proposed. METHOD: Literature review. RESULTS: The African-Caribbean population in England is at increased risk of both schizophrenia and mania; the higher rates remain when operational diagnostic criteria are used. The excess of the two psychotic disorders are probably linked: African-Caribbean patients with schizophrenia show more affective symptoms, and a more relapsing course with greater social disruption but fewer chronic negative symptoms, than White patients. No simple hypothesis explains these findings. CONCLUSIONS: More complex hypotheses are needed. One such links cultural variation in symptom reporting, the use of phenomenological constructs by psychiatrists and social disadvantage.

[Lack of gender effect on familial schizophrenia. A Brazilian study]. / Ausência de efeito de gênero em esquizofrenia familiar. Um estudo brasileiro.

Epidemiological studies on schizophrenia have showed different age at onset between gender, in which male schizophrenics present symptoms earlier than females. However this gender effect is not observed within familial schizophrenia. The present study investigates the age at onset in 31 RDC-schizophrenics from 13 Brazilian families. No differences in age at onset were found between gender, confirming previous studies in other populations. This result may indicate genetic influences on age at onset in a subgroup of patients affected by schizophrenia and can be explored by molecular genetic studies.

Ethnic differences in the presentation of bipolar affective disorder.

There have been repeated reports that Afro-Caribbean people living in the UK are more prone than white people to be diagnosed as having schizophrenia and mania, along with some evidence that they are less likely to receive a diagnosis of depression. We attempted to replicate these findings in a population of patients on lithium prophylaxis. We therefore assessed the clinical characteristics of people under the age of 55 from three ethnic groups attending a lithium clinic in south London, those of (1) white British (n = 88); (2) Afro-Caribbean (n = 31); and, (3) African (n = 15) origin. Nineteen of the white patients met DSM-IV criteria for unipolar depression (UP) and eight met the criteria for bipolar II disorder (BP II); in contrast, only two black patients met the criteria for unipolar depression and none met the criteria for BP II. Among patients diagnosed as BP I, Africans were significantly more likely than whites to show exclusively or mainly manic presentations while Afro-Caribbeans were more likely to have had mood-incongruent delusions. On the other hand, white patients were significantly more likely than Afro-Caribbeans to have had suicidal ideas or actions, and showed a similar but not significant excess when compared with Africans. Our findings could reflect either genuine ethnic differences in the presentation of severe affective disorder or be produced by the failure of British doctors to detect depression and deliver appropriate treatment to their black patients. The frequency with which Afro-Caribbean patients with mania present mood-incongruent delusions probably contributes to the high rates of diagnosed schizophrenia in this population.

Factor analysis of symptoms in schizophrenia: differences between White and Caribbean patients in Camberwell.

BACKGROUND: The incidence of schizophrenia among African-Caribbeans living in Britain has been frequently reported to be increased. We sought to determine whether the symptom profile in schizophrenic patients from this group differed from that of their White counterparts. METHODS: Factor analysis was applied to symptom data obtained by the Present State Examination (PSE) from a group of White (N = 96) and Afro-Caribbean (N = 64) patients who satisfied Research Diagnostic Criteria criteria for broad schizophrenia. We identified six symptom dimensions: mania, depression, first-rank delusions, other delusions, hallucinations and one which comprised both manic and catatonic symptoms. RESULTS: The only difference between the two ethnic groups was seen on the mixed mania-catatonia dimension with the Afro-Caribbean group being over-represented. There were no other significant differences between the groups. Discriminant analysis, however, revealed no significant differences between the groups in any dimension. CONCLUSIONS: These results indicate that there are no differences between White and African-Caribbean patients with schizophrenia in terms of the core symptoms of the disorder, however, the African-Caribbean patients may present with more symptoms of a mixed affective nature.

Is cyclic vomiting syndrome related to migraine?

OBJECTIVE: To examine the overlap between cyclic vomiting syndrome (CVS) and migraine by comparing 2 subsets of children with migraine-associated and non-migraine-associated CVS. METHODS: We studied all children <18 years of age who met the consensus criteria for CVS after presentation to our pediatric gastroenterology service from 1986 to 1998. The clinical patterns and responses to treatment were obtained from a combination of chart reviews and structured interviews. RESULTS: Among 214 children identified as having CVS, 82% were classified as having migraine-associated CVS based on 1 of 2 criteria either a family history of migraines or subsequent development of migraine headaches. Compared with the non-migraine CVS subgroup, the migraine subset had milder episodes (20.7 27.3 SD vs 39.5 66.5 emeses/episode, P =.006); more symptoms of abdominal pain (83% vs 66%), headache (41% vs 24%), social withdrawal (40% vs 22%), photophobia (36% vs 16%, all P <.05); more frequent triggering events (70% vs 49%, P =.013) including psychologic stress (39% vs 22%), physical exhaustion (23% vs 3%), and motion sickness (10% vs 0%); and a higher positive response rate to anti-migraine therapy (79% vs 36%, P =.002). CONCLUSIONS: The majority of children with CVS were subclassified as having migraine-associated CVS. The migraine-associated subgroup had less severe vomiting, manifested symptoms typical of migraine headaches, and had higher response rates to anti-migraine therapy. These findings strengthen the relationship between migraine and CVS.

A Jamaican psychiatrist evaluates diagnoses at a London psychiatric hospital.

BACKGROUND: Authors have suggested that the high rate of schizophrenia reported for African-Caribbeans living in the UK is due to misdiagnosis by British psychiatrists. AIMS: To compare the diagnoses made by a Black Jamaican psychiatrist with those of White British psychiatrists. METHOD: All in-patients on four wards at the Maudsley hospital were approached for the study; 66 participated: 24 White, 29 Black African-Caribbeans and 13 Blacks from other countries of origin. F.W.H., a Black Jamaican psychiatrist, conducted his standard clinical assessment and performed the Present State Examination (PSE) on these patients. His diagnoses were compared with the case note diagnoses made by British psychiatrists, and with the PSE CATEGO diagnoses. RESULTS: Of 29 African and African-Caribbean patients diagnosed with schizophrenia, the diagnoses of the British and the Jamaican psychiatrists agreed in 16 instances (55%) and disagreed in 13 (45%). Hence, interrater reliability was poor (kappa = 0.45). PSE CATEGO diagnosed a higher proportion of subjects as having schizophrenia than the Jamaican psychiatrist did (chi 2 = 3.74, P = 0.052). CONCLUSIONS: Agreement between the Jamaican psychiatrist and his UK counterparts about which patients had schizophrenia was poor. PSE CATEGO may overestimate rates of schizophrenia.

Linkage analysis between bipolar affective disorder and markers on chromosome X.

Since 1969, several classical linkage studies suggested an X-chromosome locus for bipolar affective disorder. However, methods using highly polymorphic DNA markers have provided conflicting evidence for linkage, and an X-chromosomal locus for bipolar disorder remains controversial. More recently, Pekkarinen et al. (1995) found a maximum LOD score of 3.54 at the marker DXS994 in a large bipolar Finnish kindred. In the present study, we attempted to replicate this finding using 43 families multiply affected by bipolar affective disorder. These families were selected for the absence of male-to-male transmission of the disease, and were genotyped for two microsatellte markers, DXS1227 and DXS1062 (which is about 2 cM telomeric to DXS994). Linkage to this region was excluded either using a two-point lod score method with two plausible genetic models, or by a model-free lod score analysis which does not require specification of a particular mode of transmission. We conclude that there is no evidence of a common major gene for bipolar affective disorder at Xq25-q27 in our set of families.

First episodes of psychosis in Afro-Caribbean and White people. An 18-year follow-up population-based study.

BACKGROUND: There have been few prospective studies of the long-term outcome of psychosis in people of Afro-Caribbean origin in the UK. METHOD: We followed-up a population-based, consecutive series of 34 Afro-Caribbean and 54 White people with psychosis who had been extensively investigated during their first admission in 1973/74. Diagnoses were made by direct interview using the Present State Examination at both first admission and follow-up. RESULTS: Ninety-seven percent of the original sample were traced. A slightly greater proportion of the Afro-Caribbean people were assigned to the S+ Catego class (schizophrenia), both on first assessment and at follow-up. No difference was found between the two groups in the consistency of diagnosis over the 18 years or in the proportion of patients considered psychotic but Afro-Caribbean people tended to have fewer negative symptoms at follow-up. There were striking differences between the two groups in their experience of psychiatric care; Afro-Caribbean people were more likely to have been readmitted, to have experienced longer hospitalisations, and to have undergone more involuntary admissions than their White counterparts. CONCLUSIONS: Afro-Caribbean people who met clinical and research criteria for schizophrenia had a less satisfactory experience of, and response to, psychiatric care over 18 years than their White counterparts.

Increased rate of psychosis among African-Caribbeans in Britain is not due to an excess of pregnancy and birth complications.

BACKGROUND: It has been suggested that the increased rate of psychotic illness among African-Caribbeans living in Britain is due to an excess of pregnancy and birth complications (PBCs). METHOD: We therefore compared the frequency of PBCs in a group of White psychotic patients (n = 103) and a comparable group of patients of African-Caribbean origin (n = 61); the latter consisted of 30 first-generation (born in the Caribbean) and 31 second-generation (born in Britain) individuals. RESULTS: White psychotic patients were more than twice as likely to have a history of PBCs as their African-Caribbean counterparts (odds ratio = 2.34, 95% confidence interval (CI) 0.88-6.47, P = 0.062). The same trend was observed among patients with a DSM-III diagnosis of schizophrenia (odds ratio = 1.65, 95% CI 0.56-4.97, P = 0.32). The rate of PBCs was similar among the first- and second-generation Caribbean psychotic patients. CONCLUSIONS: The increased rate of psychotic illness that has been reported among the African-Caribbean population in Britain is not due to an increased prevalence of PBCs.

Preferences for same race and same sex mental health workers in patients with diagnoses of psychotic illness

One hundred and forty nine patients (35 British, 114 non-white or non-British) with at least a two year history of psychotic illness, were recruited into a project designed to compare different levels of community care interventions. At recruitment into the study patients were allocated a case manager. Twelve months after recruitment patients were asked whether they had a preference for same race case managers and same race psychiatrists. Patients were also asked whether they had a preference for same sex case managers and same sex psychiatrists. Results indicate that 25.3 percent of the white British group have a preference for same race case managers, and 25.8 percent of the non-white or non-British group have a preference for same race case manager. When the non-white or non-British group is broken down it appears that second generation African-Caribbean patients are more likely than other ethnic groups to express a preference for same race case manager (p=.046). Results also indicate that 25 percent of the non-white or non-British sample have a preference for same race psychiatrist, this however, did not reach statistical significance. Although there was a trend for patients to express a preference for female case managers, this also did not reach statistical significance. Results will be discussed in terms of implications for service provision.(AU)