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

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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

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The Caribbean
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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

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Trinidad Carnival
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Trinidad and Tobago
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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)

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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

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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)

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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

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- countrys only mental hospital
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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

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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 Anns

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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

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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

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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.

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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

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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

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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

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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

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Associated Risk Factors

• African Trinidadian ethnicity
• Single Marital Status
• Cannabis Use
• Positive Family History
• Male gender
• Urban living environment
• I

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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

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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.

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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

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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

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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

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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

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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.