Lezing, 10 december 2004

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1 Lezing, 10 december 2004 Contextuele invloeden op het ontstaan van psychiatrische ziekten Prof. dr. Jim van Os Hoogleraar psychiatrie en werkzaam in het samenwerkingsverband van de GGZ instellingen in Zuid-Limburg en de Universiteit Maastricht. De groep richt zich op de invloed van de directe en wijdere sociale omgeving op het ontstaan en beloop van psychiatrische stoornissen, en hoe de GGZ dient te worden ingericht om hierop een antwoord te kunnen bieden.

2 Social Inequality = Psychiatry?

3 Social Causation and Social Selection Agerbo et al, 2004 Figure 2. Odds ratios of being unemployed more than 1% of the year for individuals with schizophrenia vs control subjects with reference to fully employed or self-employed individuals. The rates are adjusted for age, sex, calendar year, and marital status. Dotted lines are 95% confidence bands.

4 Social Selection SES Drift Residu

5 Social Disadvantage and Trauma

6 Trauma and Psychosis

7 Psychosis and ethnic group Incidence of schizophrenia and mania in Camberwell, London RR: Incidence per ,000 personyears Schizophrenia RR: 4.1 Mania African-Caribbean White Psychological Medicine,, 96 Soc. Psych. Psych. Epidemiol,, 1996

8 Person-environment environment interaction: RR=2.4 (P<0.001) RR=3.6 (P<0.001) RR=4.4 (P<0.001) High % minority population Medium % minority population Low % minority population Boydell et al, BMJ, 2002

9 Discrimination and delusional ideation Outcome No discrimination Discrimination 1 domain Discrimination > 1 domain Br J Psychiatry, 2002 Prevalence BPRS delusional ideation 0.5% (n=19) 0.9% (n=4) 2.7% (n=3) P exact: 0.027

10 The Urban PSychosis Epidemic 15% surface 50% population RR=3 Psychological Medicine,, 98, 99 Deprivation Victimisation Social capital

11 Urban at Risk Mental States Urban < Clinical 0.59% 0.93% 1.49% 1.87% 2.74% Subclinical 13.76% 13.85% 17.00% 20.24% 23.03% Arch Gen Psychiatry, 2001

12 Maastricht

13 Maastricht neighbourhoods

14 Schizophrenia standardised incidence First contact rates per 1,000,000 ( ) Random effect: P= Small areas in Maastricht

15 Buurtperspectief: achterstand indicatoren 27.0 Percentage één-ouder families 0

16 Buurtperspectief: achterstand indicatoren Percentage werkelozen per buurt in Maastricht Dit wil natuurlijk niet zeggen dat deprivatie indicatoren niet onbelangrijk zijn. Sterke variatie per buurt bv hier met werkeloosheid

17 Drukker et al, 2004 Contextuele Buurteffecten op Stoornis Risico stoornis Rijke buurt gemidddeld * Arme buurt Hoge SES Medium SES Lage SES

18 Drukker et al, 2004 Contextuele Buurteffecten op Stoornis Risico stoornis Rijke buurt gemidddeld * Arme buurt Hoge SES Medium SES Lage SES

19 Buurtdeprivatie en probleemgedrag bij kinderen Probleemgedrag gecorrigeerd voor individuele verschillen in SES 3 2,5 2 1,5 1 0,5 Kalff et al, laag midden hoog Buurt "achterstand" niveau

20 Meer gemeenschapszin! meer mensen die zich verdienstelijik maken voor de gemeenschap! meer onderscheidingen. Gelukkiger en/of gezonder gemeenschap?

21 Sociaal kapitaal in de buurt Sociale cohesie en vertrouwen Informele sociale controle Sampson et al, 97

22 Sociaal kapitaal en buurt in de US: Ervaren gezondheid Drugsgebruik & criminaliteit Hart- en vaatziekten Ervaring van stress Bron: Chicago neighbourhood project

23 Buurt steekproeven Per wijk: Sociaal kapitaal Deprivatie index

24 11-jarigen en hun ouders Soma Psyche Kwaliteit van leven Vervolgonderzoek

25 Buurteffecten op KvL lichamelijke gezondheid Negatief effect op kwaliteit van leven (gecorrigeerd) * * * Deprivatie Sociale controle Sociale cohesie Drukker et al, 2004

26 Buurteffecten op KvL geestelijke gezondheid Negatief effect op kwaliteit van leven (gecorrigeerd) Deprivatie Sociale controle * Sociale cohesiedrukker Drukker et al, 2004

27 Social Inequality = Psychiatry!

28 Social Inequality = Psychiatry Evidence social causation Understand psychiatric illness as consequence of trauma and victimisation Importance of neighbourhood wider social environment (deprivation( & social capital)

29 Fin

30 Ethnicity & SES: Social Causation Risk Schizophrenia Disadvantaged ethnic group Advantaged ethnic group Level of SES Dohrenwend et al, Science, 1992

31 Ethnicity & SES: Social Selection Risk Schizophrenia Disadvantaged ethnic group Advantaged ethnic group Level of SES Dohrenwend et al, Science, 1992

32 Ethnicity x SES Mechanism Social position Disadvantaged Ethnic group Advantaged ethnic group Dohrenwend et al, Science,, 2002

33 Schizophrenia and Single Marital Status Agerbo et al, 2004

34 The neighbourhood context 27.0 Proportion single parent families 0

35 Neighbourhood indicators " % unemployed " % dependent on benefits " % broken families "%% single households " % under 25s " % non-voters " % foreign-born " % mutations Person-level Neighbourhood-level

36 Interactive effect single marital status RR=4.2 P<0.001 RR=10.3 P<0.001 High single households area Low single households area Br J Psychiatr,, 2000

37 Tevredenheid volwassenen 8,7 8,6 8,5 8,4 8,3 8,2 8,1 8 7,9 7,8 arme buurt gemidddeld rijke buurt buurtses opleiding BuurtSES Kwaliteit van Leven lager + mavo mbo+havo/vwo hbo+wo Niet alleen tevredenheid, maar ook mental health (subschaal SF36). Ervaren gezondheid en vitality ook maar n.s.

38 Selective Migration?

39 Geographical variation: inner-city neighbourhoods Maastricht: 36 neighbourhoods

40 Causality? Discrimination / Social isolation Ethnic group Psychotic disorder

41 Urbanicity Selection Hypothesis Urb U!R R!U Rur Pedersen & Mortensen,, 2001

42 Selection: : More Than One Environmental Exposure Genetic Selection Schizophrenia

43 Selection: : More Than One Environmental Exposure Genetic Selection Schizophrenia

44 Selection: : More Than One Urbanicity/Cannabis/OCS/Ethnic Group Genetic Selection Schizophrenia

45 Selection: : More Than One Environmental Exposure Genetic Selection Schizophrenia

46 Selection: : More Than One Urbanicity/Cannabis/OCS/Ethnic Group Genetic Selection Schizophrenia

47 Selection: : More Than One Urbanicity/Cannabis/OCS/Ethnic Group Genetic Selection + Schizophrenia

48 Psychosis and ethnic group Incidence of schizophrenia and mania in Camberwell, London RR: Incidence per ,000 personyears Schizophrenia RR: 4.1 Mania African-Caribbean White Psychological Medicine,, 96 Soc. Psych. Psych. Epidemiol,, 1996

49 Follow-back Studies Camberwell (Jones et al, 1993) Groningen (Wiersma( et al, 1983) Denmark (Mortensen et al, 2003) Germany (Häfner( et al, 1995) Findings indicate substantial premorbid downward drift

50 Selection: Migration Selective Migration Urbanicity Genetic Selection Schizophrenia

51 Schizophrenia and Disability Pension Agerbo et al, 2004 Figure 2. Odds ratios of being unemployed more than 1% of the year for individuals with schizophrenia vs control subjects with reference to fully employed or self-employed individuals. The rates are adjusted for age, sex, calendar year, and marital status. Dotted lines are 95% confidence bands.

52 Ethnicity x SES Mechanism Social position Disadvantaged Ethnic group Advantaged ethnic group Dohrenwend et al Science,, 2002