Section of Old Age Psychiatry, Institute of Psychiatry, London
Maudsley Hospital, London
Section of Old Age Psychiatry, Institute of Psychiatry, London
Maudsley Hospital, London
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
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ABSTRACT |
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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.
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INTRODUCTION |
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METHOD |
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Statistics
First contact rates of SLP (including 95% confidence intervals) were
calculcated from 1997 census data on the relevant denominator population.
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RESULTS |
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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.
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DISCUSSION |
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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.
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APPENDIX |
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Clinical Implications and Limitations |
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LIMITATIONS
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Received for publication January 22, 2001. Revision received April 19, 2001. Accepted for publication April 20, 2001.
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