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.
Social Inequality = Psychiatry?
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.
Social Selection SES Drift Residu
Social Disadvantage and Trauma
Trauma and Psychosis
Psychosis and ethnic group Incidence of schizophrenia and mania in Camberwell, London 1964-1992 1992 25 RR: 2.5 20 Incidence per 15 100,000 personyears 10 5 0 Schizophrenia RR: 4.1 Mania African-Caribbean White Psychological Medicine,, 96 Soc. Psych. Psych. Epidemiol,, 1996
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
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
The Urban PSychosis Epidemic 15% surface 50% population RR=3 Psychological Medicine,, 98, 99 Deprivation Victimisation Social capital
Urban at Risk Mental States Urban <500 500-999 1000-1499 1499 1500-2499 2500 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
Maastricht 120.000
Maastricht neighbourhoods
Schizophrenia standardised incidence 90 80 70 60 50 40 30 20 10 0 15 First contact rates per 1,000,000 (1983-1995) 46 12 26 22 29 30 Random effect: P=0.05 60 44 24 23 20 97 41 25 1 6 5 Small areas in Maastricht
Buurtperspectief: achterstand indicatoren 27.0 Percentage één-ouder families 0
Buurtperspectief: achterstand indicatoren Percentage werkelozen per buurt in Maastricht 12.5 0 Dit wil natuurlijk niet zeggen dat deprivatie indicatoren niet onbelangrijk zijn. Sterke variatie per buurt bv hier met werkeloosheid
Drukker et al, 2004 Contextuele Buurteffecten op Stoornis Risico stoornis 8 7 6 5 4 3 2 1 0 Rijke buurt gemidddeld * Arme buurt Hoge SES Medium SES Lage SES
Drukker et al, 2004 Contextuele Buurteffecten op Stoornis Risico stoornis 8 7 6 5 4 3 2 1 0 Rijke buurt gemidddeld * Arme buurt Hoge SES Medium SES Lage SES
Buurtdeprivatie en probleemgedrag bij kinderen Probleemgedrag gecorrigeerd voor individuele verschillen in SES 3 2,5 2 1,5 1 0,5 Kalff et al, 2001 0 laag midden hoog Buurt "achterstand" niveau
Meer gemeenschapszin! meer mensen die zich verdienstelijik maken voor de gemeenschap! meer onderscheidingen. Gelukkiger en/of gezonder gemeenschap?
Sociaal kapitaal in de buurt Sociale cohesie en vertrouwen Informele sociale controle Sampson et al, 97
Sociaal kapitaal en buurt in de US: Ervaren gezondheid Drugsgebruik & criminaliteit Hart- en vaatziekten Ervaring van stress Bron: Chicago neighbourhood project
Buurt steekproeven Per wijk: Sociaal kapitaal Deprivatie index
11-jarigen en hun ouders Soma Psyche Kwaliteit van leven Vervolgonderzoek
Buurteffecten op KvL lichamelijke gezondheid Negatief effect op kwaliteit van leven (gecorrigeerd) 0.25-0.25-0.75-1.25-1.75-2.25-2.75 * * * Deprivatie Sociale controle Sociale cohesie Drukker et al, 2004
Buurteffecten op KvL geestelijke gezondheid Negatief effect op kwaliteit van leven (gecorrigeerd) 0.1-0.1-0.3-0.5-0.7-0.9-1.1-1.3-1.5-1.7-1.9 Deprivatie Sociale controle * Sociale cohesiedrukker Drukker et al, 2004
Social Inequality = Psychiatry!
Social Inequality = Psychiatry Evidence social causation Understand psychiatric illness as consequence of trauma and victimisation Importance of neighbourhood wider social environment (deprivation( & social capital)
Fin
Ethnicity & SES: Social Causation Risk Schizophrenia Disadvantaged ethnic group Advantaged ethnic group Level of SES Dohrenwend et al, Science, 1992
Ethnicity & SES: Social Selection Risk Schizophrenia Disadvantaged ethnic group Advantaged ethnic group Level of SES Dohrenwend et al, Science, 1992
Ethnicity x SES Mechanism Social position Disadvantaged Ethnic group Advantaged ethnic group Dohrenwend et al, Science,, 2002
Schizophrenia and Single Marital Status Agerbo et al, 2004
The neighbourhood context 27.0 Proportion single parent families 0
Neighbourhood indicators " % unemployed " % dependent on benefits " % broken families "%% single households " % under 25s " % non-voters " % foreign-born " % mutations Person-level Neighbourhood-level
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
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.
Selective Migration?
Geographical variation: inner-city neighbourhoods Maastricht: 36 neighbourhoods
Causality? Discrimination / Social isolation Ethnic group Psychotic disorder
Urbanicity Selection Hypothesis Urb U!R R!U Rur Pedersen & Mortensen,, 2001
Selection: : More Than One Environmental Exposure Genetic Selection Schizophrenia
Selection: : More Than One Environmental Exposure Genetic Selection Schizophrenia
Selection: : More Than One Urbanicity/Cannabis/OCS/Ethnic Group Genetic Selection Schizophrenia
Selection: : More Than One Environmental Exposure Genetic Selection Schizophrenia
Selection: : More Than One Urbanicity/Cannabis/OCS/Ethnic Group Genetic Selection Schizophrenia
Selection: : More Than One Urbanicity/Cannabis/OCS/Ethnic Group Genetic Selection + Schizophrenia
Psychosis and ethnic group Incidence of schizophrenia and mania in Camberwell, London 1964-1992 1992 25 RR: 2.5 20 Incidence per 15 100,000 personyears 10 5 0 Schizophrenia RR: 4.1 Mania African-Caribbean White Psychological Medicine,, 96 Soc. Psych. Psych. Epidemiol,, 1996
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
Selection: Migration Selective Migration Urbanicity Genetic Selection Schizophrenia
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.
Ethnicity x SES Mechanism Social position Disadvantaged Ethnic group Advantaged ethnic group Dohrenwend et al Science,, 2002