Urbanicity and Psychosis: Is there a Connection? A Comparative Study between an Urban and Rural Area in Portugal
DOI:
https://doi.org/10.51338/rppsm.416Keywords:
Psychotic Disorders, Rural Population, Urban PopulationAbstract
Introduction: Studies about urbanicity and psychosis show contradictory results. In northern European countries and China there is a positive relationship; in southern European and underdeveloped countries, a significant difference between rural and urban rates of psychosis has not been found.
Methods: We carried out a 5‐year retrospective observational study, with patients admitted to two inpatient units for first‐episode psychosis (FEP), in a rural area (Évora) and an urban area (Lisbon). We excluded affective or organic psychosis. Socio‐demographic and clinical data were extracted and analyzed.
Results: The prevalence of FEP was the same for both areas (42/100 000 inhabitants), with a predominance of unemployed (63%) and lonesome individuals (81% in Évora versus 72% in Lisbon). The mean age was similar (Évora 43.4 years old; Lisbon 41.4 years old). Lisbon had a greater diversity of nationalities (16.3% vs 4.6%) and a higher rate of psychotic disturbance due to substance use (26.5% vs 21.6%). The most prevalent diagnosis in the Lisbon was unspecified psychotic disorder (UPD) (34.7%), while in Évora it was delusional disorder (DD) (21.5%) and acute andtransient psychotic disorder (21.5%). DD was a prevalent diagnosis in both areas, affecting mainly women and those with a higher median age. Duration of untreated psychosis (DUP) of less than 1 month was higher in Lisbon (24.5% vs 4.5%), but there was a high prevalence of DUP of more than 2 years in both samples (20.4% vs 23.1%).
Discussion: The mean age of FEP was higher than in other studies, which may translate a significant prevalence of DD or reflect a higher DUP. A reduced DUP of less than 1 month in the rural area can be explained by greater isolation of the population, lower health literacy or better integration of patients in the community. The prevalence of UPD was higher in the urban area, possibly due to different forms of registration or a lower DUP.
Conclusion: Our results are in line with studies reported in southern European countries, where no association was found between psychosis and urbanicity, and further studies are needed to elucidate this issue.
Downloads
References
Figueira ML, Afonso P, Sampaio D. Manual de Psi‐ quiatria Clinica. Lisboa: Lidel; 2014.
Varchmin L, Montag C, Treusch Y, Kaminski J, Heinz A. Traumatic events, social adversity and discrimina‐ tion as risk factors for psychosis ‐ an umbrella review. Front Psychiatry. 2021;12:665957. doi: 10.3389/ fpsyt.2021.665957.
Toulopoulou T, Picchioni M, Mortensen PB, Petersen L. IQ, the Urban Environment, and Their Impact on Future Schizophrenia Risk in Men. Schizophr Bull. 2017;43:1056‐63. doi: 10.1093/schbul/sbw147.
Del‐Ben CM, Shuhama R, Loureiro CM, Ragazzi TC, Zanatta DP, Tenan SH, et al. Urbanicity and risk of first‐episode psychosis: incidence study in Bra‐ zil. Br J Psychiatry. 2019;215:726‐9. doi: 10.1192/ bjp.2019.110.
Krabbendam L, van Os J. Schizophrenia and urba‐ nicity: a major environmental influence‐‐conditional on genetic risk. Schizophr Bull. 2005;31:795‐9. doi: 10.1093/schbul/sbi060.
Abrahamyan Empson L, Baumann PS, Söderström O, Codeluppi Z, Söderström D, Conus P. Urbanicity: The need for new avenues to explore the link between urban living and psychosis. Early Interv Psychiatry. 2020;14:398‐409. doi: 10.1111/eip.12861.
Jongsma HE, Gayer‐Anderson C, Lasalvia A, Quat‐ trone D, Mulè A, Szöke A, et al. Treated Incidence of Psychotic Disorders in the Multinational EU‐GEI Study. JAMA Psychiatry. 2018;75:36‐46. doi: 10.1001/ jamapsychiatry.2017.3554.
Sundquist K, Frank G, Sundquist J. Urbanisation and incidence of psychosis and depression: follow‐up study of 4.4 million women and men in Sweden. Br J Psy‐ chiatry. 2004;184:293‐8. doi: 10.1192/bjp.184.4.293.
Coid JW, Zhang Y, Sun H, Yu H, Wei W, Li X, et al. Impact of urban birth and upbringing on
expression of psychosis in a Chinese undergradu‐ ate population. BMC Psychiatry. 2021;21:493. doi: 10.1186/s12888‐021‐03475‐w.
Wang C, Zhang Y. Season of birth and schizophrenia: Evidence from China. Psychiatry Res. 2017;253:189‐ ‐96. doi: 10.1016/j.psychres.2017.03.030.
DeVylder JE, Kelleher I, Lalane M, Oh H, Link BG, Koyanagi A. Association of Urbanicity With Psychosis in Low‐ and Middle‐Income Countries. JAMA Psychiatry. 2018;75:678‐86. doi: 10.1001/jamapsychiatry.2018.0577. Erratum in: JAMA Psychiatry. 2018;75:759.
Bocchetta A, Traccis F. The Sardinian Puzzle: Concentration of Major Psychoses and Suicide in the Same Sub‐Regions Across One Century. Clin Pract Epidemiol Ment Health. 2017;13:246‐54. doi: 10.2174/1745017901713010246.
Lasalvia A, Bonetto C, Tosato S, Zanatta G, Cristo‐ falo D, Salazzari D, et al. First‐contact incidence of psychosis in north‐eastern Italy: influence of age, gender, immigration and socioeconomic deprivation. Br J Psychiatry. 2014;205:127‐34. doi: 10.1192/bjp. bp.113.134445.
Schofield P, Thygesen M, Das‐Munshi J, Becares L, Cantor‐Graae E, Pedersen C, et al. Ethnic density, urbanicity and psychosis risk for migrant groups ‐ A population cohort study. Schizophr Res. 2017;190:82‐ ‐7. doi: 10.1016/j.schres.2017.03.032.
Cheng F, Kirkbride JB, Lennox BR, Perez J, Masson K, Lawrence K, et al. Administrative incidence of psy‐ chosis assessed in an early intervention service in En‐ gland: first epidemiological evidence from a diverse, rural and urban setting. Psychol Med. 2011;41:949‐58. doi: 10.1017/S0033291710002461.
Radua J, Ramella‐Cravaro V, Ioannidis JP, Reichen‐ berg A, Phiphopthatsanee N, Amir T, et al. What causes psychosis? An umbrella review of risk and protective factors. World Psychiatry. 2018;17:49‐66. doi: 10.1002/wps.20490.
Richardson L, Hameed Y, Perez J, Jones PB, Kirkbride
JB. Association of Environment With the Risk of De‐ veloping Psychotic Disorders in Rural Populations: Findings from the Social Epidemiology of Psychoses in East Anglia Study. JAMA Psychiatry. 2018;75:75‐ ‐83. doi: 10.1001/jamapsychiatry.2017.3582.
Badcock JC, Paulik G. A Clinical Introduction to Psy‐ chosis ‐ Foundations for Clinical Psychologists and Neuropsychologists. Amsterdam: Elsevier; 2020.
Fett AJ, Lemmers‐Jansen ILJ, Krabbendam L. Psy‐ chosis and urbanicity: a review of the recent liter‐ ature from epidemiology to neurourbanism. Curr Opin Psychiatry. 2019;32:232‐41. doi: 10.1097/ YCO.0000000000000486.
O’Donoghue B, Lyne JP, Renwick L, Lane A, Madigan K, Staines A, et al. Neighbourhood characteristics and the incidence of first‐episode psychosis and duration of untreated psychosis. Psychol Med. 2016;46:1367‐ ‐78. doi: 10.1017/S003329171500286X.
Zammit S, Lewis G, Rasbash J, Dalman C, Gus‐ tafsson JE, Allebeck P. Individuals, schools, and neighborhood: a multilevel longitudinal study of variation in incidence of psychotic disorders. Arch Gen Psychiatry. 2010;67(:914‐22. doi: 10.1001/ archgenpsychiatry.2010.101.
Kirkbride JB, Boydell J, Ploubidis GB, Morgan C, Dazzan P, McKenzie K, et al. Testing the association between the incidence of schizophrenia and social cap‐ ital in an urban area. Psychol Med. 2008;38:1083‐94. doi: 10.1017/S0033291707002085.
Hutchinson G, Haasen C. Migration and schizophrenia: the challenges for European psychiatry and implica‐ tions for the future. Soc Psychiatry Psychiatr Epidemi‐ ol. 2004;39:350‐7. doi: 10.1007/s00127‐004‐0766‐0.
Hou CL, Chen MY, Cai MY, Chen ZL, Cai SB, Xiao YN, et al. Antipsychotic‐Free Status in Community‐ ‐Dwelling Patients With Schizophrenia in China: Comparisons Within and Between Rural and Urban Areas. J Clin Psychiatry. 2018;79:17m11599. doi: 10.4088/JCP.17m11599.
Dolja‐Gore X, Loxton DJ, D’Este CA, Byles, J. E. Mental health service use: Is there a difference be‐ tween rural and non‐rural women in service uptake? Aust J Rural Health. 2014;22:92‐100.
Morales DA, Barksdale CL, Beckel‐Mitchener AC. A call to action to address rural mental health dispari‐ ties. J Clin Transl Sci. 2020;4:463‐7. doi: 10.1017/ cts.2020.42.
Engemann K, Pedersen CB, Arge L, Tsirogiannis C, Mortensen PB, Svenning JC. Childhood exposure to green space ‐ A novel risk‐decreasing mechanism for schizophrenia? Schizophr Res. 2018;199:142‐8. doi: 10.1016/j.schres.2018.03.026.
Frissen A, van Os J, Peeters S, Gronenschild E, Marcelis M; for Genetic Risk and Outcome in Psy‐ chosis (G.R.O.U.P.). Evidence that reduced gray matter volume in psychotic disorder is associated with
exposure to environmental risk factors. Psychiatry Res Neuroimaging. 2018;271:100‐10. doi: 10.1016/j. pscychresns.2017.11.004.
Hall SA, Kaufman JS, Ricketts TC. Defining ur‐ ban and rural areas in U.S. epidemiologic studies. J Urban Health. 2006;83:162‐75. doi: 10.1007/ s11524‐005‐9016‐3.
Ritchie H Roser M. Urbanization. [accessed Jan 2022] Available from: https://ourworldindata.org/ urbanization
Chen Y, Farooq S, Edwards J, Chew‐Graham CA, Shiers D, Frisher M, et al. Patterns of symptoms be‐ fore a diagnosis of first episode psychosis: a latent class analysis of UK primary care electronic health records. BMC Med. 2019;17:227. doi: 10.1186/ s12916‐019‐1462‐y.
O’Donoghue B, Lyne J, Madigan K, Lane A, Turner N, O’Callaghan E, et al. Environmental factors and the age at onset in first episode psychosis. Schizophr Res. 2015;168:106‐12. doi: 10.1016/j.schres.2015.07.004.
Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age‐of‐onset distributions of DSM‐IV disorders in the National Co‐ morbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593‐602. doi: 10.1001/archpsyc.62.6.593. Erratum in: Arch Gen Psychiatry. 2005;62:768.
Solmi M, Radua J, Olivola M, Croce E, Soardo L, Sa‐ lazar de Pablo G, et al. Age at onset of mental disorders worldwide: large‐scale meta‐analysis of 192 epidemi‐ ological studies. Mol Psychiatry. 2022;27:281‐95. doi: 10.1038/s41380‐021‐01161‐7.
Geddes JR, Andreasen NG. New Oxford textbook of Psychiatry. 3rd ed. Oxford: Oxford University Press; 2020.
Stegbauer C, Willms G, Kleine‐Budde K, Brames‐ feld A, Stammann C, Szecsenyi J. Development of indicators for a nationwide cross‐sectoral quality as‐ surance procedure for mental health care of patients with schizophrenia, schizotypal and delusional disor‐ ders in Germany. Z Evid Fortbild Qual Gesundhwes. 2017;126:13‐22. doi: 10.1016/j.zefq.2017.07.006.
Association American Psychiatry. Diagnostic and sta‐ tistical manual of mental disorders: DSM‐5TM. 5th ed. Chicago: American Psychiatric Publishing; 2013.
Jung YS, Kim YE, Go DS, Yoon SJ. The prevalence, incidence, and admission rate of diagnosed schizo‐ phrenia spectrum disorders in Korea, 2008‐2017: A nationwide population‐based study using claims big data analysis. PLoS One. 2021;16:e0256221. doi: 10.1371/journal.pone.0256221.
Saunders NR, Gill PJ, Holder L, Vigod S, Kurdyak P, Gandhi S, et al. Use of the emergency department as a first point of contact for mental health care by immigrant youth in Canada: a population‐based study. CMAJ. 2018;190:E1183‐91. doi: 10.1503/ cmaj.180277.
Fundação Francisco Manuel dos Santos. População residente: total e por sexo. [consultado April 2022] Available:http://www.pordata.pt
Direção Geral da Saúde. Plano nacional de saúde men‐ tal 2007—2016 e propostas prioritárias para a extensão a 2020. Lisboa: DGS; 2017.
Ministério da Saúde, Portugal. Relatório da Avaliação do Plano Nacional de Saúde Mental 2007‐2016 e pro‐ postas prioritárias para a extensão a 2020 [consultado April 2022] Available: https://saudemental.min‐saude. pt/wp‐content/uploads/2020/09/RelAvPNSM2017_ compressed.pdf
Marinucci A, Grové C, Rozendorn G. “It’s Some‐ thing That We All Need to Know”: Australian Youth Perspectives of Mental Health Literacy and Action in Schools. Front Educ. 2022;7;1‐11.
Hampson ME, Watt BD, Hicks RE, Bode A, Hampson EJ. Changing hearts and minds: The importance of for‐ mal education in reducing stigma associated with men‐ tal health conditions. Health Educ J.2018;77:198‐211.
Thirthalli J, Reddy KS, Kare M, Das S, Gangadhar BN. Rural‐urban differences in accessing mental health treatment in patients with psychosis. Int J Soc Psychia‐ try. 2017;63:694‐8. doi: 10.1177/0020764017730849.
Chu CC, Sallach HS, Klein HE. Differences in symp‐ tomatology and social adjustment between urban and rural schizophrenics. Soc Psychiatry. 1986;21:10‐4. doi: 10.1007/BF00585316.
Yang LH, Phillips MR, Li X, Yu G, Zhang J, Shi Q, et al. Employment outcome for people with schizophre‐ nia in rural v. urban China: population‐based study. Br J Psychiatry. 2013;203:272‐9. doi: 10.1192/bjp. bp.112.118927.
Hopper K, Harrison G, Janca A, Sartorius N. Recov‐ ery from Schizophrenia: An International Perspective
‐ a Report from the WHO Collaborative Project; the International Syudy of Schizofrenia. Oxford: Oxford University Press; 2007.
Jorm AF. Mental health literacy: empowering the community to take action for better mental health. Am Psychol. 2012;67:231‐43. doi: 10.1037/a0025957.
Lam Y, Broaddus ET, Surkan PJ. Literacy and healthcare‐seeking among women with low ed‐ ucational attainment: analysis of cross‐sectional data from the 2011 Nepal Demographic and Health Survey. Int J Equity Health. 2013;12:95. doi: 10.1186/1475‐9276‐12‐95.
Instituto Nacional de Estatistica. Censos 2021. [ac‐ cessed Jan 2022] Available from: https://censos.ine.pt
Santelmann H, Franklin J, Bußhoff J, Baethge C. Inter‐ rater reliability of schizoaffective disorder compared with schizophrenia, bipolar disorder, and unipolar depression ‐ A systematic review and meta‐analysis. Schizophr Res. 2016;176:357‐63. doi: 10.1016/j. schres.2016.07.012.
Sündermann O, Onwumere J, Bebbington P, Kuipers E. Social networks and support in early psychosis: potential mechanisms. Epidemiol Psychiatr Sci. 2013;22:147‐50. doi: 10.1017/S2045796012000601.
Sündermann O, Onwumere J, Kane F, Morgan C. Kui‐ pers E. Social networks and support in first‐episode psychosis: Exploring the role of loneliness and anxiety. Soc. Psychiatry Psychiatr Epidemiol. 2014;49:359–66.
Cotter J, Lin A, Drake RJ, Thompson A, Nelson B, McGorry P, et al. Long‐term employment among people at ultra‐high risk for psychosis. Schizophr Res. 2017;184:26‐31. doi: 10.1016/j.schres.2016.11.033.
