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      Ethnic Minority Status, Age-at-Immigration and Psychosis Risk in Rural Environments: Evidence From the SEPEA Study


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          Several ethnic minority groups experience elevated rates of first-episode psychosis (FEP), but most studies have been conducted in urban settings. We investigated whether incidence varied by ethnicity, generation status, and age-at-immigration in a diverse, mixed rural, and urban setting.


          We identified 687 people, 16–35 years, with an ICD-10 diagnosis of FEP, presenting to Early Intervention Psychosis services in the East of England over 2 million person-years. We used multilevel Poisson regression to examine incidence variation by ethnicity, rural–urban setting, generation status, and age-at-immigration, adjusting for several confounders including age, sex, socioeconomic status, population density, and deprivation.


          People of black African (incidence rate ratio: 4.06; 95% confidence interval [CI]: 2.63–6.25), black Caribbean (4.63; 95% CI: 2.38–8.98) and Pakistani (2.31; 95% CI: 1.35–3.94) origins were at greatest FEP risk relative to the white British population, after multivariable adjustment. Non-British white migrants were not at increased FEP risk (1.00; 95% CI: 0.77–1.32). These patterns were independently present in rural and urban settings. For first-generation migrants, migration during childhood conferred greatest risk of psychotic disorders (2.20; 95% CI: 1.33–3.62).


          Elevated psychosis risk in several visible minority groups could not be explained by differences in postmigratory socioeconomic disadvantage. These patterns were observed across rural and urban areas of our catchment, suggesting that elevated psychosis risk for some ethnic minority groups is not a result of selection processes influencing rural–urban living. Timing of exposure to migration during childhood, an important social and neurodevelopmental window, may also elevate risk.

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          Most cited references41

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            Language and theory of mind: meta-analysis of the relation between language ability and false-belief understanding.

            Numerous studies show that children's language ability is related to false-belief understanding. However, there is considerable variation in the size of the correlation reported. Using data from 104 studies (N=8,891), this meta-analysis determines the strength of the relation in children under age 7 and examines moderators that may account for the variability across studies--including aspect of language ability assessed, type of false-belief task used, and direction of effect. The results indicate a moderate to large effect size overall that remains significant when age is controlled. Receptive vocabulary measures had weaker relations than measures of general language. Stronger effects were found from earlier language to later false belief than the reverse. Significant differences were not found among types of false-belief task.
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              A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants.

              There is increasing acceptance of migration as a risk factor for schizophrenia and related disorders; however, the magnitude of the risk among second-generation immigrants (SGIs) remains unclear. Generational differences in the incidence of psychotic disorders among migrants might improve our understanding of the relationship between migration, ethnicity and psychotic disorders. This meta-analysis aimed at determining the risk of psychotic disorders among SGIs in comparison with non-migrants and first-generation immigrants (FGIs). Medline, EMBASE and PsycINFO databases were searched systematically for population-based studies on migration and psychotic disorders published between 1977 and 2008. We also contacted experts, tracked citations and screened bibliographies. All potential publications were screened by two independent reviewers in a threefold process. Studies were included in the meta-analysis if they reported incidence data, differentiated FGIs from SGIs and provided age-adjusted data. Data extraction and quality assessment were conducted for each study. Twenty-one studies met all inclusion criteria. A meta-analysis of 61 effect sizes for FGIs and 28 for SGIs yielded mean-weighted incidence rate ratios (IRRs) of 2.3 [95% confidence interval (CI) 2.0-2.7] for FGIs and 2.1 (95% CI 1.8-2.5) for SGIs. There was no significant risk difference between generations, but there were significant differences according to ethno-racial status and host country. The increased risk of schizophrenia and related disorders among immigrants clearly persists into the second generation, suggesting that post-migration factors play a more important role than pre-migration factors or migration per se. The observed variability suggests that the risk is mediated by the social context.

                Author and article information

                Schizophr Bull
                Schizophr Bull
                Schizophrenia Bulletin
                Oxford University Press (US )
                October 2017
                17 May 2017
                17 May 2017
                : 43
                : 6
                : 1251-1261
                [1 ] PsyLife Group, Division of Psychiatry, University College London , London, UK
                [2 ] Department of Psychiatry, University of Cambridge , Cambridge, UK
                [3 ] Norfolk & Suffolk Foundation Trust , Norwich, UK
                [4 ] Cambridgeshire & Peterborough Foundation Trust and NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East of England , Cambridge, UK
                [5 ] North Essex Partnership NHS Foundation Trust , Chelmsford, UK
                Author notes
                [* ]To whom correspondence should be addressed; Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1T 7NF, UK; tel: 44-(0)-20-7679-9297, e-mail: j.kirkbride@ 123456ucl.ac.uk
                © The Author 2017. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

                Page count
                Pages: 11
                Regular Articles

                epidemiology,ethnicity,migration,urbanicity,incidence,early intervention,social determinants
                epidemiology, ethnicity, migration, urbanicity, incidence, early intervention, social determinants


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