Social Context Returns to Psychosis Research

Social context matters in the course of psychosis.

Recent research findings on the effects of immigration and of minority status within a community appear to strengthen the case for an effect of social context on psychosis, said Ezra Susser, M.D., Dr.P.H., at APA's 2009 Institute on Psychiatric Services in New York in October.

Credit: Ellen Dallager

“Schizophrenia has its origins in early brain development, but unlike some other neurodevelopmental disorders, the trajectory is not predetermined and the disorder may be partially reversible,” Susser said. “Psychosis has a heterogenous course and outcome that can be affected by family relationships, treatment, and the sociocultural environment in which the patient lives.”

Susser outlined a history of research on social context in psychosis beginning with the DosMed (Determinants of Outcome of Severe Mental Disorders) Study, published in 1986. This study surprised some people because its findings indicated that outcomes appeared to be better in developing countries than in developed countries and that there was a 10-fold higher rate of nonaffective acute remitting psychoses in developed countries.

Susser said the DosMed report was an exception during an era of overall decline in studies of social context. This decline was due in part to what he called “the myth of 1 percent”—the conventional wisdom that the prevalence of schizophrenia was always and everywhere 1 percent of a given population; it was also due in part to emerging evidence that psychosis was not inversely related to the socioeconomic status of the family of origin.

“This led most, though not all, researchers to abandon the search for social clues to the disorder,” Susser said. He is professor of epidemiology at Columbia University's Mailman School of Public Health and a professor of psychiatry at the New York State Psychiatric Institute.

More recently, he said, the search for social clues in the course and outcome of psychosis has been revived with the emergence of epigenetics—the study of the way gene expression can be altered by forces, including environmental ones, other than changes in basic DNA structure. And research published within the last two years looking at immigration and the effect of discrimination and minority status within a community has added powerful new evidence of the influence of social context.

Salient Events May Explain Some Risk

Today, the study of social context and psychosis is illustrated by research on the effects of paternal age, “urbanicity,” cannabis use, and immigrant and minority status.

Societal factors influence the age at which parents bear children, and older paternal age has been associated with greater risk of psychosis in offspring. The latter is believed to be due to either the accumulation of toxic exposures with aging that affect DNA or simply an increase in errors in DNA replication with aging, Susser said.

Similarly, studies have reported an increased risk of schizophrenia with use of cannabis, as well as a dose-response relationship between cannabis use and psychosis. “Contextual influences on cannabis use include social norms, drug policies, and generational effects,” Susser said.

A number of studies in recent years have indicated that “urbanicity,” or urban living, is associated with an increased risk of psychosis. A prominent theory for explaining the association, Susser said, points to the quantity of “salient events”—intrusive experiences that command attention—associated with urban living and the evidence that schizophrenia may be a disorder of “salience regulation.”

The sheer number of salient events may overwhelm the ability of the at-risk individual to organize and regulate his or her environment, Susser explained.

Some of the most powerful evidence for the influence of social context on psychosis comes from studies of immigration and minority status. A 2005 meta-analysis by Elizabeth Cantor-Graae, Ph.D., and Jean-Paul Selten, Ph.D., M.D., in the American Journal of Psychiatry looked at population-based incidence studies concerning immigrants in the United Kingdom, Netherlands, Denmark, and Sweden appearing between 1977 and 2003 and calculated relative risks for migrant groups for each study.

They found that the mean weighted relative risk for developing schizophrenia among first-generation migrants was 2.7. Subgroup comparisons yielded significantly greater effect sizes for migrants from areas where the majority of the population is black.

Cantor-Graae and Salten concluded that a personal or family history of migration is an important risk factor for schizophrenia and that the differential risk pattern across subgroups suggests a role for psychosocial adversity in the etiology of schizophrenia.

“The association cannot be explained by higher rates of psychosis in the country of origin, selective migration, diagnostic bias, or by differences in pathways to care,” Susser said. “Rather, it would appear to be the effect of something—social networks, language fluency, stigma, discrimination and harassment, or other psychosocial factors—in the experience of being an immigrant or minority.”

Ethnic Density Examined

A study coauthored by Susser and published in the January 2008 American Journal of Psychiatry examined the role of “ethnic density”—the proportion of a neighborhood population represented by one's own ethnic group—as a possible mediator in the effect of immigration on psychosis risk. The study looked at incidence rates for native Dutch and first- and second-generation immigrants from Morocco, Surinam, and Turkey living in the Hague, Netherlands (Psychiatric News, February 1, 2008).

The ethnic density of a neighborhood was computed for each immigrant group as the proportion of residents belonging to that group, and statistical analysis provided a prediction of the incidence of psychotic disorders as a function of individual ethnicity and neighborhood ethnic density, controlling for other potentially confounding factors.

What Susser and colleagues found was that the risk of schizophrenia in all of the immigrant groups was higher than that for native Dutch, and that for all of the immigrant groups the risk was higher in low-density neighborhoods—that is, in neighborhoods where an immigrant was less likely to be surrounded by others from his or her native country. For Moroccans living in a low-density neighborhood, the risk was almost three times higher than it was for Moroccans living in a high-density neighborhood.

The findings are a powerful indicator of the potential importance of environmental and psychosocial influences in the etiology of schizophrenia, since the effect of ethnic density on risk would appear to admit no other explanation but a social and environmental one.

“What's so interesting about this is that if it is true that ethnic density matters, then it is very difficult to explain it except by some social process—that is, the interactions between yourself and the people around you,” Susser told Psychiatric News in an interview when the study was published. “The most parsimonious explanation for this phenomenon is that it is something in the social life of individuals who develop psychosis that contributes to the increased risk.”

“Schizophrenia and Migration: A Meta-Analysis and Review” is posted at <http://ajp.psychiatryonline.org/cgi/content/full/162/1/12>. “Ethnic Density of Neighborhoods and Incidence of Psychotic Disorders Among Immigrants” is posted at <http://ajp.psychiatryonline.org/cgi/content/full/162/1/12>.