Skip to main page content

• HOME
• Current
• Archive
• Feedback
• Subscribe
• Help

This Article Abstract Full Text (PDF) Submit an eLetter Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Related articles in BJP Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by REEVES, S. J. Articles by HOWARD, R. J. Search for Related Content PubMed PubMed Citation Articles by REEVES, S. J. Articles by HOWARD, R. J.

The British Journal of Psychiatry (2001) 179: 172-174
© 2001 The Royal College of Psychiatrists

Increased first-contact rates for very-late-onset schizophrenia-like psychosis in African- and Caribbean-born elders

SUZANNE J. REEVES, MRCPsych

Section of Old Age Psychiatry, Institute of Psychiatry, London

JUSTIN SAUER, MBBS

Maudsley Hospital, London

ROBERT STEWART, MRCPsych

Section of Old Age Psychiatry, Institute of Psychiatry, London

ANNABEL GRANGER, MRCPsych

Maudsley Hospital, London

ROBERT J. HOWARD, MD

Section of Old Age Psychiatry, Institute of Psychiatry, London

Correspondence: Dr Suzanne Reeves, Institute of Psychiatry, Section of Old Age Psychiatry, De Crespigny Park, London SE5 8AF, UK. Tel: 020 7848 0550; fax 020 7701 0167; e-mail: s.reeves{at}iop.kcl.ac.uk

Declaration of interest None.

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION APPENDIX Clinical Implications and... REFERENCES

 
Background Studies have consistently shown a higher incidence of schizophrenia with onset in early adult life in African and Caribbean migrants to the UK.

Aims To establish the incidence (first-contact rates) of very-late-onset (>60 years) schizophrenia-like psychosis (SLP) in south London and to test the hypothesis that this is higher among African- and Caribbean-born than indigenous elders.

Method We identified all new referrals of SLP to the Maudsley Hospital between 1995 and 2000. Demographic details, including age, ethnicity and electoral ward (address), were obtained from case notes. Incidence was estimated using 1997 census data to determine the denominator population for each ethnic group.

Results The incidence of SLP was significantly higher in African- and Caribbean-born than indigenous elders: 172.4 per 100 000 population (95% CI=57.9-286.8) in African- and Caribbean-born males and 323.5 per 100 000 population (95% CI 167.8-479.1) in African- and Caribbean-born females. Rates also were increased in elders from other immigrant groups, but the numbers involved were too small to reach accepted levels of significance.

Conclusions Large-scale epidemiological studies are needed to determine both the incidence of and the coexistent risk factors for SLP among all elderly migrants, who may constitute a group with high service needs.

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION APPENDIX Clinical Implications and... REFERENCES

 
Over the past three decades, studies have consistently shown a higher incidence of schizophrenia among African and Caribbean migrants to the UK in comparison with the indigenous population (McGovern & Cope, 1987; Harrison et al, 1997). This does not appear to be explained by misdiagnosis (Hickling & Rodgers-Johnson, 1995), admission bias (Bebbington et al, 1981) or underestimation of the denominator population (King et al, 1994; Van Os et al, 1996; Bhugra et al, 1997). High rates of schizophrenia have been shown in some populations of older African and Caribbean patients (>65 years), although studies have failed to differentiate cases according to age of onset (Redlinghuys & Shah, 1997; Odutoye & Shah, 1999). Epidemiological data on the late-onset psychoses are scarce, in part owing to controversies over classification and nosology. The incidence of late-onset schizophrenia (onset of illness at over 40 years of age) (Howard et al, 2000) has been reported at 12.6 per 100 000 population per year (Copeland et al, 1998). The incidence of very-late-onset schizophrenia-like psychosis (SLP) (onset of illness at over 60 years of age) (Howard et al, 2000) is 17-24 per 100 000 population (Holden, 1987); in addition, incidence is positively correlated with age, increasing by 11% for every 5-year increase in age (Van Os et al, 1995).

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION APPENDIX Clinical Implications and... REFERENCES

 
Sample
All new referrals (>65 years) to Old Age Psychiatry Services at the Maudsley Hospital, London, over a 5-year period (April 1995-April 2000) were examined. Patients were identified from initial summary letters, liaison with multi-disciplinary team members and by cross-reference with in-patient data. For all patients identified, case notes were reviewed to verify the diagnosis and to obtain demographic details, including ethnicity (recorded as place of birth). The diagnosis of SLP was made only if strict criteria were satisfied (see Appendix). Ethnic group was assigned using the Office for National Statistics classification (Sillitoe, 1987). For the study analysis, this classification was simplified into three categories: British-born, African- and Caribbean-born (Black African, Black Caribbean, Black Other), and ‘Other’ (all other immigrant groups, including Irish, Polish, Asian, Vietnamese). Electoral ward was assigned using address at the time of referral. The denominator population (>65 years) for each ethnic category within each electoral ward was calculated using census data from the 1997 Office for National Statistics Mid-year Estimates (see Schuman, 1999).

Statistics
First contact rates of SLP (including 95% confidence intervals) were calculcated from 1997 census data on the relevant denominator population.

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION APPENDIX Clinical Implications and... REFERENCES

 
First contact rates of schizophrenia-like psychosis
A total of 75 SLP patients were referred between April 1995 and April 2000. Of these, three (one male, two females) were excluded because they lived out of the area at the time of referral. Of the 61 remaining, 25 patients (41%) were British-born, 26 (42.6%) were African- and Caribbean-born and 10 (16.4%) came from ‘Other’ immigrant groups. Incidence (first-contact) rates of SLP per 100 000 population, with 95% confidence intervals, are shown in Table 1. The rate of SLP was significantly higher in African- and Caribbean-born than in British-born elders; 12 times higher in females and 24 times higher in males. Rates of SLP in ‘Other’ immigrant elders also appeared higher than in British-born elders; confidence intervals, however, were wide owing to small numbers in the denominator population, and the findings therefore were not significant.

View this table: [in this window] [in a new window]

Table 1 Schizophrenia-like psychosis (SLP): first contacts, April 1995—April 2000

First-contact rates of non-psychotic disorders
It was possible that service contacts for African- and Caribbean-born elders were overrepresented for all psychiatric diagnoses in our original sample, owing to selective bias on the part of local referrers. To investigate this we examined all new referrals over a 1-year period (1999) to determine the proportion of African- and Caribbean-born elders referred with non-psychotic disorders. There were 378 new referrals in 1999, of which 189 (50%) case notes were selected randomly for review. Of the 173 referred with non-psychotic disorders, the diagnostic categories were as follows: dementia/organic disorders (including alcohol misuse), 57.8%; affective/anxiety disorders (including obsessive-compulsive disorder), 37.5%; other psychiatric diagnoses (including adjustment reaction, personality disorder and ‘no psychiatric diagnosis’), 8%. Contact rates for dementia/organic disorders were twice as high in African- and Caribbean-born than in British-born elders (2.3 times higher in African- and Caribbean-born females and 2.1 times higher in males). This is comparable with previous data (McCracken et al, 1997). In contrast, contact rates for depression/ anxiety disorders were 2.3 times higher in British-born than in African- and Caribbean-born males, with no differences being seen between females in the two groups.

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION APPENDIX Clinical Implications and... REFERENCES

 
Case ascertainment
Misdiagnosis was highly unlikely in our sample because strict diagnosis criteria were used to identify patients with SLP. The use of out-patient first-contact data, although avoiding biases secondary to hospitalisation policies, inevitably underestimates the true incidence of SLP in the community because many elderly patients with paranoia do not seek help (Christenson & Blazer, 1984). There is, however, no reason to assume that this bias is greater for indigenous elders than for African- and Caribbean-born migrants. Bias on the part of local referrers appears unlikely because referral rates for non-psychotic disorders were not disproportionately increased in African- and Caribbean-born elders. It is possible, however, that referral bias was diagnosis-specific.

Population denominator data
It is possible that census data underestimated the African/Caribbean denominator population, but this would need to have occurred by a factor of 10 to explain the observed differences and is highly unlikely (Schuman, 1999).

Risk factors for schizophrenia-like psychosis
First-contact rates were calculated separately for males and females in the sample, thus avoiding gender-related bias. Our findings of a higher contact rate of SLP among females from all ethnic groups support previous data on gender-related risk (Howard et al, 2000). Considering age as a risk factor for SLP (Van Os et al, 1995), data have shown all migrant groups to have a younger age profile than the indigenous population (Schuman, 1999). We may therefore be underestimating the incidence rates of SLP among both African- and Caribbean-born and other immigrant elders from our sample.

First-contact rates of schizophrenia-like psychosis
To our knowledge, this is the first study to examine first-contact rates of SLP among different ethnic groups. The general paucity of data on SLP is a reflection of both the difficulties relating to classification and the exclusion of those over 60 years old from many epidemiological studies of psychotic disorders (Howard et al, 2000). Our findings suggest that African- and Caribbean-born elders have a significantly higher incidence of SLP than their indigenous counterparts. Higher rates of SLP also may be present in other immigrant elders, suggesting a pattern similar to that seen in young adults (Hitch & Rack, 1980; Bebbington et al, 1981; King et al, 1994; Bracken et al, 1998), but numbers were too small to allow accurate interpretation. It is unclear, therefore, whether specific risk factors relate to African- and Caribbean-born migrants or whether common environmental risk factors exist among all immigrant elderly groups. Certainly, epidemiological data suggest that social isolation, deprivation and physical ill health are more common among migrant populations (Hitch & Rack, 1980; Schoenbaum & Waidmann, 1997; Bracken et al, 1998; Silveira & Ebrahim, 1998; Burnett et al, 1999). There is evidence also that migrants of African and Caribbean origin may be more compromised than others with respect to social isolation, because a higher proportion live alone (Burnett et al, 1999; Schuman, 1999) and they are more likely to have earlier experiences of social exclusion owing to unemployment (Bhugra et al, 1997). Large-scale epidemiological research is needed to explore socio-economic differences between elderly migrant populations and to determine their relationship with SLP.

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION APPENDIX Clinical Implications and... REFERENCES

 
The criteria for very-late-onset schizophrenia-like psychosis are:

1. Onset of symptoms over the age of 60 years.
   
2. Presence of fantastic, persecutory, referential or grandiose delusions, with or without hallucinations.
   
3. Absence of primary affective disorder.
   
4. Intellectual capacity in keeping with that of normal ageing: Mini-Mental State Examination (MMSE) no less than 25/30.
   
5. No clouding of consciousness.
   
6. No history of neurological illness/alcohol dependence.
   
7. Normal haematological/biochemical screen (including Venereal Disease Research Laboratory).
   

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION APPENDIX Clinical Implications and... REFERENCES

 
CLINICAL IMPLICATIONS

• African- and Caribbean-born elders are a vulnerable group in terms of their risk of developing organic and functional mental illness. This has implications for future service provision.
  
• The increased rate of psychosis in African- and Caribbean-born elders is comparable to that described previously in younger African and Caribbean adults born in the UK.
  
• Co-existent risk factors and prognostic indicators for schizophrenia-like psychosis (SLP) need to be evaluated in African- and Caribbean-born and other migrant populations.
  

LIMITATIONS

• Out-patient referral data provide information only about those in contact with mental health services.
  
• The number of individuals with SLP from other immigrant groups was too small to allow interpretation of results.
  
• Data on co-existent risk factors for psychosis were unavailable.
  

TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION APPENDIX Clinical Implications and... REFERENCES

 

1. Bebbington, P. E., Hurry, J. & Tennant, C. (1981) Psychiatric disorders in selected immigrant groups in Camberwell. Social Psychiatry, 16, 43-51.[CrossRef]
2. Bhugra, D., Leff, J., Mallett, R., et al (1997) Incidence and outcome of schizophrenia in whites, African—Caribbeans and Asians in London. Psychological Medicine, 27, 791-798.[CrossRef][Medline]
3. Bracken, P. J., Greenslade, L., Griffin, B., et al (1998) Mental health and ethnicity: an Irish dimension. British Journal of Psychiatry, 172, 103-105.[Free Full Text]
4. Burnett, R., Mallett, R., Bhugra, D., et al (1999) The first contact of patients with schizophrenia with psychiatric services: social factors and pathways to care in a multi-ethnic population. Psychological Medicine, 29, 475-483.[CrossRef][Medline]
5. Christenson, R. & Blazer, D. (1984) Epidemiology of persecutory ideation in an elderly population in the community. American Journal of Psychiatry, 141, 59-67.
6. Copeland, J. R. M., Dewey, M. E., Scott, A., et al (1998) Schizophrenia and delusional disorder in older age: community prevalence, incidence, comorbidity and outcome. Schizophrenia Bulletin, 24 (1), 153-161.
7. Harrison, G., Glazebrook, C., Brewin, J., et al (1997) Increased incidence of psychotic disorders in migrants from the Caribbean to the United Kingdom. Psychological Medicine, 27, 799-806.[CrossRef][Medline]
8. Hickling, F.W. & Rodgers-Johnson, P. (1995) The incidence of first-contact schizophrenia in Jamaica. British Journal of Psychiatry, 167, 193-196.[Abstract/Free Full Text]
9. Hitch, P.J. & Rack, P. H. (1980) Mental illness among Polish and Russian refugees in Bradford. British Journal of Psychiatry, 137, 206-211.[Abstract/Free Full Text]
10. Holden, N. L. (1987) Late paraphrenia or the paraphrenias? A descriptive study with a 10-year follow-up. British Journal of Psychiatry, 150, 635-639.[Abstract/Free Full Text]
11. Howard, R., Rabins, P.V., Seeman, M. V., et al (2000) Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. American Journal of Psychiatry, 157, 172-178.[Abstract/Free Full Text]
12. King, M., Coker, E., Leavey, G., et al (1994) Incidence of psychotic illness in London: comparison of ethnic groups. British Medical Journal, 309, 1115-1119.[Abstract/Free Full Text]
13. McCracken, C. F. M., Boneham, M. A., Copeland, J. R. M., et al (1997) Prevalence of dementia and depression among elderly people in Black and ethnic minorities. British Journal of Psychiatry, 171, 269-273.[Abstract/Free Full Text]
14. McGovern, D. & Cope, R. V. (1987) First psychiatric admission rates of first and second generation Afro Caribbeans. Social Psychiatry, 22, 139-149.
15. Odutoye, K. & Shah, A. (1999) The characteristics of Indian subcontinent origin elders newly referred to a psychogeriatric service. Internal Journal of Geriatric Psychiatry, 14, 446-453.[CrossRef][Medline]
16. Redlinghuys, J. & Shah, A. K. (1997) The characteristics of ethnic elders from the Indian subcontinent using a geriatric psychiatry service in West London. Ageing and Mental Health, 1, 243-247.[CrossRef]
17. Schoenbaum, M. & Waidmann, T. (1997) Race, socioeconomic status, and health: accounting for race differences in health. Journal of Gerontology, 52B, 61-73.
18. Schuman, J. (1999) The ethnic minority populations of Great Britain — latest estimates. Population Trends, 96, 33-43.
19. Sillitoe, K. (1987) Asking About Race. London: Office of Population Censuses and Surveys.
20. Silveira, E. R. T. & Ebrahim, S. (1998) Social determinants of psychiatric morbidity and well-being in immigrant whites in East London. International Journal of Geriatric Psychiatry, 13, 801-812.[CrossRef][Medline]
21. Vas Os, J., Howard, R., Takei, N., et al (1995) Increasing age as a risk factor for psychosis in the elderly. Social Psychiatry and Psychiatric Epidemiology, 30, 161-164.[CrossRef][Medline]
22. Van Os, Castle, D. J., Takei, N., et al (1996) Psychotic illness in ethnic minorities:clarification from the 1991 census. Psychological Medicine, 26, 203-208.[Medline]

Received for publication January 22, 2001. Revision received April 19, 2001. Accepted for publication April 20, 2001.

Related articles in BJP:

Highlights of this issue

ELIZABETH WALSH
BJP 2001 179: 0. [Full Text]  

This article has been cited by other articles:

				O. A. Ayonrinde, S. Reeves, R. Stewart, and R. Howard Schizophrenia-like psychosis in African and Caribbean elders Authors' reply The British Journal of Psychiatry, February 1, 2002; 180(2): 187 - 187. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Submit an eLetter Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Related articles in BJP Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Citing Articles via Scopus Google Scholar Articles by REEVES, S. J. Articles by HOWARD, R. J. Search for Related Content PubMed PubMed Citation Articles by REEVES, S. J. Articles by HOWARD, R. J.