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ENVIRONMENTAL
EPIDEMIOLOGY OF
PSYCHOSES:
Lessons from Nottingham
Jouko MiettunenDepartment of Public Health and Primary CareInstitute of Public HealthUniversity of Cambridge June 17th, 2003
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PSYCHOTIC DISORDERSchronic, severe, and disabling brain diseases
life-time prevalence approximately 1% in schizophrenia 1% other psychoses
more common in urban than in rural areasmore common in western countries
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POSSIBLE ENVIRONMENTAL RISK FACTORS
related to urban birth or to upbringingpopulation densitystressful life-events air pollution social deprivation temporal order can be the opposite
social drift? more healthy people may move out from deprived
areas?
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Nottingham Health Authority Area
about 600,000 people in 105 electoral wardsdistricts of Nottingham, Ruschliffe, Broxtowe,
Gedling and Ashfieldseveral previous studies (1969-1988) on
schizophrenia and other psychoses possible to estimate trends in incidence
relatively high social deprivation and incidence of schizophrenia
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SAMPLES OF THE STUDYSIN DATA
“Schizophrenia Incidence in Nottingham” all incidence cases of psychoses in Nottingham Health Authority Area
1.6.1992 - 31.5.1994 167 cases (166 with known address)
ÆSOP DATA “Aetiology and Ethnicity in Schizophrenia and Other Psychoses” three-centre study (other centres are Bristol and South London) all incidence cases of psychoses in Nottingham Health Authority Area
1.8.1997 - 31.7.1999 206 cases (202 with known address)
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INDIVIDUAL VARIABLES DISTRIBUTIONS 1992-94 (N=167) 1997-99 (N=206)
Gender: males 98 (59%) 123 (60%)Median age 28 y 30 yDiagnoses
Narrow schizophrenia 56 67 Broad schizophrenia 82 116 Affective psychosis 85 90
Ethnic groups White 122 (73%) 159 (77%) African-Caribbean 26 (16%) 26 (13%) Other 19 (11%) 21 (10%)
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POPULATION DATA
Census 1991 population of Nottingham population at risk (16 to 64 years): 389,389 after under-enumeration corrections: 399,439
till 1992-94 population has increased approximately 2%
and till 1997-99 approximately 6% from this estimate
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ELECTORAL WARD LEVEL VARIABLESMultiple Deprivation Index 2000
Income Employment Housing Health deprivation and disability Education, skills and training Geographical access to services
population densityproportion of ethnic minorities
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HYPOTHESES OF THE STUDY
Incidence of psychoses is higher in more deprived areas (and/or in areas with higher population density)
Incidence of psychoses among ethnic minorities is relatively higher in areas with lower proportion of ethnic minorities
lack of social support?
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CASES 1992-94
02
1 5
0
210
22
1
11 3
01
0
4
1
04
2
23
01
1 0
0
0
2
01 01
12 01
00
1
017 4 3
113
0 04
1044
68
0
98 512
056 6
35 0 0
0
2 2 50
0
00 20
1 11 0 00 000
000
00
0
0 1
1
0
Deprivation:High to low
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11
3 4
2
011
11
0
10 4
11
0
3
0
64
0
23
00
0 1
0
0
1
10 01
42 00
20
0
038 5 4
320
0 07
0045
89
0
52 552
044 4
80 1 1
0
4 6 02
0
13 30
3 35 4 22 033
101
00
0
0 1
1
1
CASES 1997-99
Deprivation:High to low
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ANNUAL INCIDENCE OF ALL PSYCHOSES BY SOCIAL DEPRIVATIONNOTTINGHAM 1992-1994
34 24
170
77
18 14
160
71
18 15
222
53
12 11
272
00
50
100
150
200
250
300
ALL white afro-c. others
I (high)
IV(low)
IIIII
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39 29
204
64
19 16
128
53
22 20
167
70
20 18
136
69
0
50
100
150
200
250
ALL white afro-c. others
ANNUAL INCIDENCE OF ALL PSYCHOSES BY SOCIAL DEPRIVATIONNOTTINGHAM 1997-1999
I (high)IIIIIIV (low)
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PLAN FOR ANALYSES
Age-standardised rates (Nottingham as a standard)Two studies separately and pooledResults by
Sex Ethnic groupSubdiagnoses
narrow schz, broad schz and affective psychosiseach of the six variables in the deprivation score
Poisson regression analyses
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LIMITATIONS
Electoral ward as a unit?
Case-ascertainment?
Census population?
Social deprivation scores? analyses can be repeated with other scores
Causality?
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FUTURE WORK (1)Smaller units than electoral wards
enumeration districts (no information on ethnicity) using e.g. principal component analysis
Census 2001 variables are soon available update all the analyses with new population data update all the the analyses with new social deprivation variables combinations of census 1991 and 2001 variables
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FUTURE WORK (2)
Case-control study of ÆSOP multilevel analyses with individual level variables
e.g. social class
ÆSOP is a three-centre study replicate the analyses in Bristol and South London
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CONCLUSIONS
Preliminary findings: incidence of schizophrenia is about 1.5 more
common in the most deprived areas
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CONCLUSIONS
Preliminary findings: incidence of schizophrenia is about 1.5 more
common in the most deprived areas
Much more work is needed in this thesis and also elsewhere to study social deprivation and incidence of psychoses
All your comments will be very helpful
Thank You!