Individuals, Schools, and Neighborhood: A Multilevel Longitudinal Study of Variation in Incidence of Psychotic Disorders | Psychiatry and Behavioral Health | JAMA Psychiatry | JAMA Network
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McGrath  JSaha  SChant  DWelham  J Schizophrenia: a concise overview of incidence, prevalence, and mortality.  Epidemiol Rev 2008;3067- 76PubMedGoogle ScholarCrossref
McGrath  JSaha  SWelham  JEl Saadi  OMacCauley  CChant  D A systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology.  BMC Med 2004;213PubMedGoogle ScholarCrossref
Faris  RDunham  H Mental Disorders in Urban Areas.  Chicago, IL: University of Chicago Press; 1939
Lewis  GDavid  AAndréasson  SAllebeck  P Schizophrenia and city life.  Lancet 1992;340 (8812) 137- 140PubMedGoogle ScholarCrossref
March  DHatch  SLMorgan  CKirkbride  JBBresnahan  MFearon  PSusser  E Psychosis and place.  Epidemiol Rev 2008;3084- 100PubMedGoogle ScholarCrossref
Mortensen  PBPedersen  CBWestergaard  TWohlfahrt  JEwald  HMors  OAndersen  PKMelbye  M Effects of family history and place and season of birth on the risk of schizophrenia.  N Engl J Med 1999;340 (8) 603- 608PubMedGoogle ScholarCrossref
Harrison  GFouskakis  DRasmussen  FTynelius  PSipos  AGunnell  D Association between psychotic disorder and urban place of birth is not mediated by obstetric complications or childhood socio-economic position: a cohort study.  Psychol Med 2003;33 (4) 723- 731PubMedGoogle ScholarCrossref
Kirkbride  JBFearon  PMorgan  CDazzan  PMorgan  KMurray  RMJones  PB Neighbourhood variation in the incidence of psychotic disorders in Southeast London.  Soc Psychiatry Psychiatr Epidemiol 2007;42 (6) 438- 445PubMedGoogle ScholarCrossref
Laursen  TMMunk-Olsen  TNordentoft  MBo Mortensen  P A comparison of selected risk factors for unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia from a Danish population-based cohort.  J Clin Psychiatry 2007;68 (11) 1673- 1681PubMedGoogle ScholarCrossref
Lloyd  TKennedy  NFearon  PKirkbride  JMallett  RLeff  JHolloway  JHarrison  GDazzan  PMorgan  KMurray  RMJones  PBAESOP study team, Incidence of bipolar affective disorder in three UK cities: results from the AESOP study.  Br J Psychiatry 2005;186126- 131PubMedGoogle ScholarCrossref
Pedersen  CBMortensen  PB Urbanicity during upbringing and bipolar affective disorders in Denmark.  Bipolar Disord 2006;8 (3) 242- 247PubMedGoogle ScholarCrossref
Eaton  WWMortensen  PBFrydenberg  M Obstetric factors, urbanization and psychosis.  Schizophr Res 2000;43 (2-3) 117- 123PubMedGoogle ScholarCrossref
Kirkbride  JBMorgan  CFearon  PDazzan  PMurray  RMJones  PB Neighbourhood-level effects on psychoses: re-examining the role of context.  Psychol Med 2007;37 (10) 1413- 1425PubMedGoogle ScholarCrossref
van Os  JDriessen  GGunther  NDelespaul  P Neighbourhood variation in incidence of schizophrenia. Evidence for person-environment interaction.  Br J Psychiatry 2000;176243- 248PubMedGoogle ScholarCrossref
Cantor-Graae  ESelten  JP Schizophrenia and migration: a meta-analysis and review.  Am J Psychiatry 2005;162 (1) 12- 24PubMedGoogle ScholarCrossref
Pedersen  CBMortensen  PB Family history, place and season of birth as risk factors for schizophrenia in Denmark: a replication and reanalysis.  Br J Psychiatry 2001;17946- 52PubMedGoogle ScholarCrossref
Moore  THZammit  SLingford-Hughes  ABarnes  TRJones  PBBurke  MLewis  G Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review.  Lancet 2007;370 (9584) 319- 328PubMedGoogle ScholarCrossref
Wicks  SHjern  AGunnell  DLewis  GDalman  C Social adversity in childhood and the risk of developing psychosis: a national cohort study.  Am J Psychiatry 2005;162 (9) 1652- 1657PubMedGoogle ScholarCrossref
van Os  JHanssen  MBak  MBijl  RVVollebergh  W Do urbanicity and familial liability coparticipate in causing psychosis?  Am J Psychiatry 2003;160 (3) 477- 482PubMedGoogle ScholarCrossref
Kirkbride  JBFearon  PMorgan  CDazzan  PMorgan  KTarrant  JLloyd  THolloway  JHutchinson  GLeff  JPMallett  RMHarrison  GLMurray  RMJones  PB Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center AeSOP study.  Arch Gen Psychiatry 2006;63 (3) 250- 258PubMedGoogle ScholarCrossref
Allardyce  JBoydell  J Review: the wider social environment and schizophrenia.  Schizophr Bull 2006;32 (4) 592- 598PubMedGoogle ScholarCrossref
Boydell  Jvan Os  J McKenzie  KAllardyce  JGoel  R McCreadie  RGMurray  RM Incidence of schizophrenia in ethnic minorities in London: ecological study into interactions with environment.  BMJ 2001;323 (7325) 1336- 1338PubMedGoogle ScholarCrossref
Drukker  MKrabbendam  LDriessen  Gvan Os  J Social disadvantage and schizophrenia. A combined neighbourhood and individual-level analysis.  Soc Psychiatry Psychiatr Epidemiol 2006;41 (8) 595- 604PubMedGoogle ScholarCrossref
Silver  EMulvey  EPSwanson  JW Neighborhood structural characteristics and mental disorder: Faris and Dunham revisited.  Soc Sci Med 2002;55 (8) 1457- 1470PubMedGoogle ScholarCrossref
Lofors  JSundquist  K Low-linking social capital as a predictor of mental disorders: a cohort study of 4.5 million Swedes.  Soc Sci Med 2007;64 (1) 21- 34PubMedGoogle ScholarCrossref
Skapinakis  PLewis  GAraya  RJones  KWilliams  G Mental health inequalities in Wales, UK: multi-level investigation of the effect of area deprivation.  Br J Psychiatry 2005;186417- 422PubMedGoogle ScholarCrossref
Thomas  HWeaver  NPatterson  JJones  PBell  TPlayle  RDunstan  FPalmer  SLewis  GAraya  R Mental health and quality of residential environment.  Br J Psychiatry 2007;191500- 505PubMedGoogle ScholarCrossref
Weich  SHolt  GTwigg  LJones  KLewis  G Geographic variation in the prevalence of common mental disorders in Britain: a multilevel investigation.  Am J Epidemiol 2003;157 (8) 730- 737PubMedGoogle ScholarCrossref
Veling  WSusser  Evan Os  JMackenbach  JPSelten  JPHoek  HW Ethnic density of neighborhoods and incidence of psychotic disorders among immigrants.  Am J Psychiatry 2008;165 (1) 66- 73PubMedGoogle ScholarCrossref
Andréasson  SAllebeck  PRydberg  U Schizophrenia in users and nonusers of cannabis. A longitudinal study in Stockholm County.  Acta Psychiatr Scand 1989;79 (5) 505- 510PubMedGoogle ScholarCrossref
Dalman  CBroms  JCullberg  JAllebeck  P Young cases of schizophrenia identified in a national inpatient register—are the diagnoses valid?  Soc Psychiatry Psychiatr Epidemiol 2002;37 (11) 527- 531PubMedGoogle ScholarCrossref
Kristjansson  EAllebeck  PWistedt  B Validity of the diagnosis of schizophrenia in a psychiatric inpatient register.  Nord Psychiatr Tidskr 1987;41 (3) 229- 234Google ScholarCrossref
Rasbash  JCharlton  CBrowne  WJHealy  MCameron  B MLwiN Version 2.1.  Bristol, England: Centre for Multilevel Modelling, University of Bristol; 2009
Browne  WJ MCMC Estimation in MLwiN, v2.13.  Bristol, England: Centre for Multilevel Modelling, University of Bristol; 2009
Chandola  TBartley  MWiggins  RSchofield  P Social inequalities in health by individual and household measures of social position in a cohort of healthy people.  J Epidemiol Community Health 2003;57 (1) 56- 62PubMedGoogle ScholarCrossref
Duncan  CJones  KMoon  G Psychiatric morbidity: a multilevel approach to regional variations in the UK.  J Epidemiol Community Health 1995;49 (3) 290- 295PubMedGoogle ScholarCrossref
Fone  DDunstan  FWilliams  GLloyd  KPalmer  S Places, people and mental health: a multilevel analysis of economic inactivity.  Soc Sci Med 2007;64 (3) 633- 645PubMedGoogle ScholarCrossref
Wainwright  NWSurtees  PG Area and individual circumstances and mood disorder prevalence.  Br J Psychiatry 2004;185227- 232PubMedGoogle ScholarCrossref
Congdon  P Suicide and parasuicide in London: a small area study.  Urban Stud 1996;33 (1) 137- 158Google ScholarCrossref
Kirkbride  JBBoydell  JPloubidis  GBMorgan  CDazzan  P McKenzie  KMurray  RMJones  PB Testing the association between the incidence of schizophrenia and social capital in an urban area.  Psychol Med 2008;38 (8) 1083- 1094PubMedGoogle ScholarCrossref
Thompson  WD Effect modification and the limits of biological inference from epidemiologic data.  J Clin Epidemiol 1991;44 (3) 221- 232PubMedGoogle ScholarCrossref
Zammit  SWiles  NLewis  G The study of gene–environment interactions in psychiatry: limited gains at a substantial cost?  Psychol Med 2010;40 (5) 711- 716Google ScholarCrossref
Selten  JPCantor-Graae  E Social defeat: risk factor for schizophrenia?  Br J Psychiatry 2005;187101- 102PubMedGoogle ScholarCrossref
Covington  HE  IIIMiczek  KA Repeated social-defeat stress, cocaine or morphine. Effects on behavioral sensitization and intravenous cocaine self-administration “binges.”  Psychopharmacology (Berl) 2001;158 (4) 388- 398PubMedGoogle ScholarCrossref
Kapur  S Psychosis as a state of aberrant salience: a framework linking biology, phenomenology, and pharmacology in schizophrenia.  Am J Psychiatry 2003;160 (1) 13- 23PubMedGoogle ScholarCrossref
Laruelle  M The role of endogenous sensitization in the pathophysiology of schizophrenia: implications from recent brain imaging studies.  Brain Res Brain Res Rev 2000;31 (2-3) 371- 384PubMedGoogle ScholarCrossref
Fletcher  PCFrith  CD Perceiving is believing: a Bayesian approach to explaining the positive symptoms of schizophrenia.  Nat Rev Neurosci 2009;10 (1) 48- 58PubMedGoogle ScholarCrossref
Durkheim  E Suicide: A Study in Sociology.  New York, NY: Free Press; 1951
Kawachi  IKennedy  BP Health and social cohesion: why care about income inequality?  BMJ 1997;314 (7086) 1037- 1040PubMedGoogle ScholarCrossref
Robinson  D The search for community cohesion: key themes and dominant concepts of the public policy agenda.  Urban Stud 2005;42 (8) 1411- 1427Google ScholarCrossref
Original Article
September 2010

Individuals, Schools, and Neighborhood: A Multilevel Longitudinal Study of Variation in Incidence of Psychotic Disorders

Author Affiliations

Author Affiliations: MRC Centre for Neuropsychiatric Genetics and Genomics, Department of Psychological Medicine and Neurology, School of Medicine, Cardiff University, Cardiff, Wales (Dr Zammit); Academic Unit of Psychiatry (Drs Zammit and Lewis) and Centre for Multilevel Modelling (Dr Rasbash), University of Bristol, Bristol, England; Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden (Drs Dalman and Allebeck); and Department of Education, University of Göteborg, Göteborg, Sweden (Dr Gustafsson).

Arch Gen Psychiatry. 2010;67(9):914-922. doi:10.1001/archgenpsychiatry.2010.101

Context  Incidence of schizophrenia and other nonaffective psychoses is greater in urban than rural areas, but the reason is unclear. Few studies have examined whether both individual and neighborhood characteristics can explain this association. Furthermore, as has been shown for ethnicity, the effect of individual characteristics may depend on neighborhood context.

Objectives  To examine (1) whether individual, school, or area characteristics are associated with psychosis and can explain the association with urbanicity and (2) whether effects of individual characteristics on risk of psychosis vary according to school context (reflecting both peer group and neighborhood effects).

Design  Multilevel longitudinal study of all individuals born in Sweden in 1972 and 1977. Diagnoses were identified through linkage with the Swedish National Patient Register until December 31, 2003.

Setting  Population-based.

Participants  A total of 203 829 individuals with data at individual, school, municipality, and county levels.

Main Outcome Measures  Any nonaffective psychosis, including schizophrenia (881 subjects; 0.43% cumulative incidence). For the study of interactions, the outcome was any psychosis (1944 subjects; 0.95% cumulative incidence).

Results  Almost all the variance in risk of nonaffective psychosis was explained by individual-level rather than higher-level variation. An association between urbanicity and nonaffective psychosis was explained by higher-level characteristics, primarily school-level social fragmentation. We observed cross-level interactions between individual- and school-level markers of ethnicity, social fragmentation, and deprivation on risk of developing any psychotic disorder, all with qualitative patterns of interaction.

Conclusions  The association between urbanicity and psychosis appears to be a reflection of increased social fragmentation present within cities. The qualitative interactions observed are consistent with a hypothesis that certain characteristics that define individuals as being different from most other people in their local environment may increase risk of psychosis. These findings have potentially important implications for understanding the etiology of psychotic disorders and for informing social policy.