AESOP-10 - The causes of ethnic differences in the course and outcome of psychosis

Lead Research Organisation: King's College London
Department Name: Psychological Medicine


We will address two of the most important issues facing the UK mental health services. Firstly, what factors impair recovery following onset of psychosis in people of any ethnicity? The NHS has made a huge investment in units for the early treatment of individuals with their first episode of psychosis. However, little is known about which factors facilitate or impair long-term recovery, and therefore which patients and which characteristics should be the focus of intensive treatment. Secondly, why do African-Caribbean and Black African people living in the UK have a poorer outcome of psychosis with more compulsory admissions and detention in forensic units than White people? This issue has been the subject of much controversy and repeated statutory inquiries. Unfortunately the resultant reports have produced little improvement, probably because of the lack of hard evidence on which to base their recommendations.

We wish to re-examine the 535 people whom we extensively investigated, with the support of the MRC, when they suffered their first episode of psychosis 10 years previously. We will investigate the role of biological factors (such as brain, neurological and neuropsychological abnormalities), social factors (such as childhood adversity, and adult social exclusion and discrimination), and continued cannabis use in determining the outcome of psychosis, and whether these factors differ by ethnicity. In this way, we will shed light on A) whether factors such as severity of symptoms, neuropsychological impairments, social adversity, and cannabis use and its interaction with genetic make-up, can predict who will recover in the sample as a whole; B) why Black patients have a worse outcome with more compulsory admissions and detentions in forensic units. Our findings will improve understanding of psychosis, and will point to ways of developing more appropriate services for psychotic patients in general and Black patients in particular.

Technical Summary

1. BACKGROUND We will address two of the most important issues facing UK Mental Health Services: The first is that the NHS has made a huge investment in establishing early intervention programmes for individuals suffering their first psychotic episode. However, there is little information available about what factors predict long-term outcome, and therefore which patients should be the focus of particularly energetic treatment. The second is that there are very high rates of psychosis among Black people living in the UK. Furthermore, Black people so diagnosed have a worse outcome with more compulsory admissions to psychiatric units and detentions in high security psychiatric hospitals than White people.

2. AIMS a). We will identify the factors that predict the course and outcome of psychosis following a first episode, focusing specifically on the role of biological and social risk indicators, cannabis use, and duration of untreated psychosis.

b). We will study and explain the differences in the course and outcome of psychosis in Black and White patients in the decade following a first episode.

2. AESOP COHORT Between 1997-1999, in an MRC-funded study, we collected an ethnically diverse epidemiologically-based cohort of 535 individuals during their first episode of psychosis. Extensive baseline data were collected concerning clinical characteristics, neuropsychology, brain imaging, and exposure to childhood and adult social adversity. The epidemiological basis of the sample and wealth of baseline information will enable us to answer questions about the long-term outcome of psychosis in people of different ethnicities which have not been adequately addressed.

3. METHODS We will re-examine these 535 cases ten years after their initial assessment. We will repeat the initial investigations, and collect information about their subsequent experience of life and illness. We hypothesise that three sets of variables will predict course and outcome, as follows: a) ‘Biological‘ risk indicators will predict chronicity: b) Social risk indicators will predict a relapsing course with more positive symptoms: c) Continued cannabis use will predict clinical and social decline. We further hypothesise that ethnic differences will be explicable in terms of greater exposure to social adversity in Black patients, and the interaction between cannabis use and the COMT genotype. The study has high statistical power, and will allow tests of interaction and exploration of more complex models.

4. IMPLICATIONS Our findings will provide valuable information about the contemporary outcome of psychosis, and how to develop more appropriate services for psychotic individuals, particularly Black Britons.


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