Five-year illness trajectories across racial groups in the UK following a first episode psychosis
Introduction
The evidence that psychosis disproportionally affects ethnic minority groups in high-income countries is clearly established within literature. Pakistani, Bangladeshi and those of mixed backgrounds in England have twice the incidence rate of developing psychosis compared to the White population (Kirkbridge et al., 2012). Black Caribbean are five times more likely to develop psychosis in the UK, however this increased incident rate is not evidenced in Caribbean countries (Bhugra et al., 1996). Research into the disparities in outcomes of psychosis, however, is less conclusive. Birchwood and colleagues (1992) found increased relapse and readmission rates in Black Caribbean individuals compared to Asian and White individuals. Socioeconomic circumstances such as family structure, time until access to care, and employment status were suggested as confounding factors for this disproportion in clinical outcomes. However, Griffiths and colleagues noted that methodological constraints, including small samples and high attrition rates, mean drawing robust and reliable conclusions about differing outcome trajectories for ethnic minority participants is not yet possible.
Griffiths et al. (2023) set out to explore clinical and social outcomes for young people of different minority backgrounds recovery from a first episode of psychosis (FEP) within early intervention services (EIS).
Method
A sample of 978 participants was gathered and data analysed from UK-wide NIHR SUPEREDEN study (a large, national, longitudinal dataset of patients receiving EI).
Results
Outcomes were measured using the following scales: PANSS, CDSS, GAF-D, DUP. Social deprivation was operationalised as the presence of unemployment, single marital status, living alone, and living in temporary/supported accommodation.
Outcome data were available for 912 participants at baseline and 296 participants at 5 years follow up (33% retention). By year 5, the sample included:
• 23 Black individuals
• 52 Asian individuals
• 221 White individuals
Chi square tests and ANOVA tests were performed on the measures between groups at baseline and follow up. Linear mixed effect models with random intercept and slopes were used to model outcomes trajectories. The authors found evidence of the following:
• Rate of improvement varied across racial groups; the White group showed more growth in their clinical and social trajectories compared to the Black and Asian groups
• Social deprivation contributed to the variance in recovery growth across groups
• Social deprivation was associated with higher PANNS positive and negative scores, higher Calgary depression scores, and lower GAF scores
• Black and Asian individuals were more likely to remain under mental health services 2 years post EIS discharge
• Black individuals had significantly higher levels of deprivation than Asian individuals over the duration of the study
• The White group had a significantly longer duration of untreated psychosis however reported the same level of psychotic symptoms at baseline compared to the ethnic minority groups
Strengths and Limitations
The authors highlight several strengths of this research. This study offers the first investigation into outcomes across ethnic minority groups following discharge from an Early Intervention Service. Authors further the current literature by exploring outcomes for Asian individuals, a heritage which lacks robust evidence when considering FEP and outcomes. The study also draw upon a large, perspective cohort of individuals across the UK, meaning socioeconomic variability is represented within the study.
However, the authors note that within the baseline and follow up sample, the target ethnic minority groups were notably smaller than the White population, reducing the statistical power of the study. The smaller comparison ethnic minority groups also limits the representativeness of the findings, particularly given the evidence base for a higher prevalence of psychosis within ethnic minority groups in countries, such as the UK. The authors findings may be impacted by bias for this reason. Another limitation of this research is the high rate of attrition between baseline and 5-year follow up, also allowing for bias in their findings. However, Griffiths and colleagues were able to demonstrate that the missing data did not differ between racial groups. Finally, although the study offered a novel insight into the racial disparities in recovery following EIS, the implications of the research may have been furthered with the inclusion of specific ethnic minority groups and an analysis of intergroup differences. This may include, as outlined by the authors, a mixed-race population and Black-African population.
Overall, Griffiths et al. offer a commendable insight into the variation in long-term clinical and social recovery following care from Early Intervention Services after individuals experience a first episode of psychosis. This study offers clear direction for future research which includes replication, consideration of premorbid social deprivation, intergroup differences, and exploring the key contributing factors behind the disparities. The findings can be applied within EIS to promote holistic and targeted early interventions following FEP in Black and Asian populations.
Conclusion
The authors conclude that their results evidence disparities in long term social and clinical outcomes during recovery of FEP across racial groups, particularly variation between racial minority and non-minority groups. Griffiths and colleagues also suggest wider contextual and societal factors influence illness trajectories, specifically social deprivation. These findings, though requiring replication, implicate the need for culturally sensitive and targeted service mitigating the impact of social deprivation to promote FEP recovery within racial minority groups.
Written By Hana Shah, Assistant Psychologist - At Risk Mental State (ARMS) Service at Forward Thinking Birmingham
References
Bhugra D et al (1996) First-contact incidence rates of schizophrenia in Trinidad and one-year follow-up. Br J Psychiatry 169:587–592. https://doi.org/10.1192/bjp.169.5.587
Griffiths, S.L., Bogatsu, T., Longhi, M. et al (2023). Five-year illness trajectories across racial groups in the UK following a first episode psychosis. Soc Psychiatry Psychiatr Epidemiol (2023). https://doi.org/10.1007/s00127-023-02428-w
Kirkbride JB et al (2012) Incidence of schizophrenia and other psychoses in England, 1950–2009: a systematic review and metaanalyses. PLoS One 7:e31660. https://doi.org/10.1371/journal.pone.0031660
Morgan C et al (2017) Ethnicity and long-term course and outcome of psychotic disorders in a UK sample: the ÆSOP-10 study. Br J Psychiatry 211:88–94. https://doi.org/10.1192/bjp.bp.116.193342
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