Aetiology of Psychosis in People of Caribbean Origin the view from Trinidad and Tobago

1. Aetiology of Psychosis in People of Caribbean Origin � the view from Trinidad and Tobago Gerard Hutchinson Faculty of Medical Sciences University of the West Indies

2. The Caribbean

3. Facts about Trinidad and Tobago Land Area � Trinidad 4828 sq km ; Tobago 300 sq km GDP � US $ 20 billion Per capita income � US $ 16000 Resources � crude oil, natural gas, timber, fish Oil and natural gas account for 45% of GDP

4. Trinidad Carnival

5. Trinidad and Tobago

6. Interest in Caribbean Psychosis Reports of increased rates of mental illness in West Indian migrants to England (Gordon, 1964; Kiev, 1965) Many subsequent incidence studies Increased rates in second generation (Harrison et al, 1988) Environmental risk factors implicated (Hutchinson et al, 1996)

7. Middle Passage Revisited Dem black fellers should stop stinking up de place in England by going mad, if they wanted to go mad, they coulda stay home VS Naipaul, 1962 �The Middle Passage� Quoting one of his companions on the journey back to the Caribbean

8. Incidence in African Caribbeans � UK and the Caribbean Fearon et al 2006 � 7.1/10000 (UK) King et al (1994) 5.1/10000 (UK) Bhugra et al (1997) 4.7/10000 (UK) Mahy et al (1999) 2.8/10000 (Barbados) Hickling & Rodgers- Johnson (1995) 2.1/10000 (Jamaica) Bhugra et al (1996) 1.6 /10000 (Trinidad)

9. Study Background Population 1.3 mill. - 40% each African and Indian; 20% Mixed. Modelled on AESOP in Britain Incidence of the major psychoses in the country Role of established risk factors Case control study First contact with mental health services � public and private, out and in-patients

10. - country�s only mental hospital

11. Perceptions of mental illness (Hutchinson et al, 1999 ) 33% of medical students believe that cause is supernatural Would resist social contact � cooking, marrying, friendship Fear of violence Major reason for admission � violent behaviour Littlewood (1989) � �benign stigma�

12. Mental Health Services in TT One psychiatric hospital Mental health services � delivered by geographic catchment area - 7 sectors and Tobago Tobago (15 beds) and San Fernando (24 beds) have psychiatric units within the respective general hospitals, Patients who are violent and/or have a high risk of absconding sent to St Ann�s

13. Background Approximately 1000 psychiatric beds in country Outpatient services in each sector 25 psychiatrists in the country � public and private practice : 1 per 52000 population Substance abuse and child psychiatry services in regional hospitals

14. Methods All first contact cases of psychosis presenting to mental health services � public and private for one year period (2003 - 2004) Age range 15-64 Interviewed to confirm psychotic symptoms, Exclusion criteria - mental retardation, known cerebral pathology, previous psychotic presentation Informed consent Sociodemographic and clinical interviews using SCAN and other AESOP derived schedules

15. Recruitment of Controls Age and gender matched Living within 5 house radius Exclusion of psychotic symptoms Sociodemographic and clinical schedules including substance use and family history.

16. Methods Interview with relatives- PPHS, Family history, pregnancy and birth complications, duration of untreated psychosis Diagnosis by clinical consensus �researcher and treating consultant � DSM-IV Statistical analysis � SPSS � 10.0

17. Results Total Cases n = 424 - 242 males ; 182 females Controls n = 430 - 242 males ; 188 females Schizophrenia n = 162 - 102 males Bipolar Disorder n = 67- 42 males Substance Use n = 56 - 50 males Psychotic Depression n = 61 - 18 males Other n = 78 - 30 males

18. Incidence Schizophrenia 2.0/10000 Bipolar Disorder 0.8/10000 Substance Induced Psychosis 0.7/10000 Psychotic Depression 0.7/10000 Acute Psychotic Episode /Szform 0.4/10000

19. Age and Gender Distribution Mean Age � males 28.6 ; females 34.8 15-29 age group, 63.6% male to 42.8% female (P = 0.01) 40-59 age group 18.6% males to 31.3% females (P = 0.006) Schizophrenia in males 2.7/10000 In females 1.2/10000

20. Associated Risk Factors African Trinidadian ethnicity Single Marital Status Cannabis Use Positive Family History Male gender Urban living environment I

21. Ethnicity Incidence of schizophrenia greater in people of African origin (RR 2.5, 95% CI 1.6 - 3.8) Incidence of bipolar disorder greater in people of African origin (RR 1.8 95% CI 1.2 - 3.0) Co-morbid cannabis and cocaine abuse greater in cases of African origin Co-morbid alcohol use greater in cases of Indian origin. Correlated with psychotic depression

22. Substance Use Among cases with schizophrenia, frequent cannabis use in previous year OR 3.7, 95% CI 1.8 � 5.1). Cannabis use in cases compared to controls OR 7.3 (95% CI 4.6-10.3)In males, cannabis use approx. ten times more likely in patients with schizophrenia compared to controls.

23. Substance Use Among patients 45% chronic use of cannabis 15% abuse cocaine , 19% abuse alcohol. 81% use two or more substances. No evidence for use of amphetamines, hallucinogens or heroin Aggressive and violent behaviour 8 times more common among those with history of substance use Admission 6 times more likely with substance use history

24. Family History Presence of family history increases risk OR 3.9 (1.5 - 5.7) With cannabis use OR 5.8 (2.1-10.7) More likely to be male Morbid risk consistent with White British population

25. Discussion Incidence rates compare with those previously reported in the Caribbean for schizophrenia. Cannabis use and family history - major risk factors Association with ethnicity because of cannabis use Ethnic skew of diagnoses : African- Trinidadian ethnicity more common in schizophrenia Indo-Trinidadians � overrepresented in alcohol related and depression

26. Limitations Leakage of cases Case notes used for some cases Distinction between substance related psychosis and affective or non-affective psychosis Access to services in rural areas Use of traditional and religious practitioners

27. Issues to Resolve Ethnic differentiation of mental health presentations Geographic association of urbanicity; psychosis and homicide (rates doubled in past 3 years- 35/100000 And rural life, depression and suicide (12/100000 � 2nd to Guyana in the English speaking Caribbean.