BMJ 2001;323:1336 ( 8 December )

Papers

Incidence of schizophrenia in ethnic minorities in London: ecological study into interactions with environment

J Boydell, clinical researcher a, J van Os, professor b, K McKenzie, clinical researcher a, J Allardyce, lecturer c, R Goel, research assistant a, R G McCreadie, professor c, R M Murray, professor of psychiatry a. 

a Division of Psychological Medicine, Institute of Psychiatry, Denmark Hill, London SE5 8AF, b Department of Psychiatry and Neuropsychology, European Graduate School of Neuroscience, Maastricht University, PO Box 616, 6200 MD Maastricht, Netherlands, c Department of Clinical Research, Crichton Royal Hospital, Dumfries DG1 4TG

Correspondence to: J Boydell j.kelly{at}iop.kcl.ac.uk


    Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References

Objective: To determine whether the incidence of schizophrenia among people from non-white ethnic minorities is greater in neighbourhoods where they constitute a smaller proportion of the total population.
Design: Ecological design including retrospective study of case records to calculate the incidence of schizophrenia in the ethnic minority population across electoral wards and multi-level analysis to examine interaction between individuals and environment.
Setting: 15 electoral wards in Camberwell, South London.
Participants: All people aged 16 years and over who had contact with psychiatric services during 1988-97.
Main outcome measure: Incidence rates of schizophrenia according to Research Diagnostic Criteria.
Results: The incidence of schizophrenia in non-white ethnic minorities increased significantly as the proportion of such minorities in the local population fell. The incidence rate ratio varied in a dose-response fashion from 2.38 (95% confidence interval 1.49 to 3.79) in the third of wards where non-white ethnic minorities formed the largest proportion (28-57%) of the local population to 4.4 (2.49 to 7.75) in the third of wards where they formed the smallest proportion (8-22%).
Conclusion: The incidence of schizophrenia in non-white ethnic minorities in London is greater when they comprise a smaller proportion of the local population.


What is already known on this topic
An increased incidence of schizophrenia has been reported in several ethnic minorities in the United Kingdom

Biological risk factors do not seem to explain this

Reports from the United States have shown an association between the proportion of an ethnic minority living in an area and their admission rates for mental illness in general

What this study adds
The lower the proportion of non-white ethnic minorities in a local area the higher the incidence of schizophrenia in those minorities




    Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References

Schizophrenia is a serious illness that results in considerable burden to sufferers, carers, and society. Understanding its aetiology is extremely important. An increased incidence of schizophrenia has been consistently reported in people of African-Caribbean and African origin who are resident in the United Kingdom1-3 and less consistently so in those of south Asian origin. 4 5 As the excess cannot be explained by any known biological risk factor, investigation has turned to the possible role of social environment.6-10

Research in the United States has shown an association between the proportion of an ethnic minority living in a particular area and their rates of admission for mental illness,11 but a national study in the United Kingdom could not replicate these findings.12 Clarification of this issue is important not only because of what it may tell us about the aetiology of schizophrenia but also because ethnic minority groups are gradually dispersing throughout the United Kingdom.

We investigated whether the proportion of ethnic minorities in a given area was associated with their incidence rate of schizophrenia at an electoral ward level. Our hypothesis was that the incidence rate of schizophrenia in ethnic minorities would be highest in wards where they made up a smaller proportion of the population. We examined data on all new contacts with the psychiatric services over a 10 year period and used multi-level modelling techniques to examine interactions between individuals and environment.


    Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References

Identification of participants
We collected clinical and demographic information on all people from a defined area of south London (previously the London Borough of Camberwell) who presented with psychosis during 1988-97. All psychiatric services for the area during this period were provided by the Bethlem Royal and Maudsley NHS Trust through hospital and community teams. We identified cases from hospital computer records by generating a list of all people admitted with any possible psychotic illness as defined by ICD-9 (international classification of diseases and related health problems, ninth revision) codes 295, 295.6, 296, 296.2, 296.4, 297, 298, and 292.1, and ICD-10 (tenth revision) codes F20, 25, 22, 30, 31.3, 31.2, 31.6, 28, 29, 12.5, 16.6, 19.5, 16.75, and 19.75. We also examined case notes of all patients from the area who had psychiatric hospital records to identify people who made contact with services but were not admitted to hospital.

We checked case records to ensure the individuals were true incident cases (that is, they had not previously had contact with psychiatric services) and rated them using the operational checklist for psychotic disorders.13 Two authors, JK and JvO, carried out the ratings, and inter-rater reliability for Research Diagnostic Criteria schizophrenia14 was good (kappa =0.79). The checklist is based on phenomenological descriptions in the present state examination15 and enables a computer diagnosis of Research Diagnostic Criteria schizophrenia to be made with the associated computer program.16

Ethnic and sociodemographic status
We classified ethnicity on the basis of that recorded by the patients themselves, according to categories used by the Office of Population Censuses and Surveys. We also noted the patient's and his or her parents' place of birth, when available, and any description of colour (mental state examinations routinely comment on appearance). We used this information to determine ethnicity for those patients who did not have statements of self assigned ethnicity. A check on this method was carried out by Castle et al, who compared results with those from previous direct interviews and found no errors in 34 patients.17 Because the population projections at ward level were not accurate enough to calculate population data separately for each ethnic minority, we were able to split the population into only two groups: a white group (self assigned ethnicity white) and non-white group (all other self assigned ethnicities). The non-white population was about 40% Caribbean, 30% African, and 10% other. Incident cases were assigned to either white or non-white groups. Thus the effect we measured was that of non-white ethnic minority status.

The area (about 120 000 people) was divided into electoral wards of about 10 000 people, which had different socioeconomic characteristics. We used the address at presentation to the services to identify wards for all incident cases. We estimated population data using the 1991 census18 and London Research Centre projections, which include corrections for undernumeration and information about housing, mortality, and migration.19 For the years 1992-7 our calculations were based on a linear interpolation using 1991 census data and 1997 population projection data. For the years 1988-90 we extrapolated data on the basis of the 1991-7 data. No further interpolation was attempted before 1988, so that the all analyses relate to the period 1988-97. Socioeconomic status at ward (neighbourhood) level was based on a composite deprivation score (Department of Environment index of local conditions),20 which includes unemployment, overcrowding, child poverty, lack of amenities, low earnings, no car, and low level of education (but not ethnic group).

Analysis
We carried out indirect standardisation with the Research Diagnostic Criteria rates of schizophrenia for the total 10 year population as the standard and applied them to each ward, stratifying for age, sex, and ethnic minority using the ISTDIZE procedure in the Stata statistical program (StataCorp, College Station, TX). The standardisation used the stratum specific rates of the standard population to calculate the expected number of cases for each ward and the adjusted incidence rates at ward level. We calculated the standardised incidence ratio by dividing the number of cases observed by the expected number.

By using the Stata XTPOIS multilevel Poisson regression modelling procedure, we examined two types of effects: firstly, the ward random effects---that is, are the wards different with regard to the incidence of schizophrenia; and, secondly, ward and individual fixed effects---that is, does the factor being studied make neighbourhoods different with regard to the incidence of schizophrenia. We examined the fixed effects of age, sex, and non-white ethnic minority status at the individual level and deprivation and ethnic density (proportion of ethnic minorities) in thirds of distribution (highest, middle, lowest) at ward level. We carried out multilevel Poisson regression analysis to calculate incidence rate ratios for Research Diagnostic Criteria schizophrenia for individual and ward variables and to test for interaction between non-white ethnic minority status at the individual level and proportion of non-white ethnic minority at the neighbourhood level. Interaction terms were assessed by likelihood ratio tests. We adjusted associations between schizophrenia and individual level non-white ethnic minority status and ward level proportion of non-white ethnic minority for age, sex, and ward level of deprivation.


    Results
Top
Abstract
Introduction
Methods
Results
Discussion
References

For the period 1988-97 we identified 126 (57%) men and 96 (43%) women as first onset cases, all of whom met Research Diagnostic Criteria schizophrenia. The mean age was 35.4 years (SD 18.0), and 126 (57%) were non-white. Of the white patients, 10 were born in the Republic of Ireland and five were born outside the United Kingdom or Republic of Ireland.

The multi-level Poisson model of incidence of schizophrenia without covariates showed a significant random ward effect (chi 2=3.9, df=1, P<0.05), indicating that wards differed with respect to incidence of schizophrenia. The incidence, adjusted for individual level age, sex, and non-white ethnic group, varied from 12 to 38 per 100 000 person years (table 1). Table 2 shows the effects of explanatory variables on incidence rate ratios at individual and neighbourhood level.


                              
View this table:
[in this window]
[in a new window]
 

Table 1. Incidence and standardised incidence ratio of Research Diagnostic Criteria schizophrenia according to operational checklist for psychotic disorders


                              
View this table:
[in this window]
[in a new window]
 

Table 2. Influence of explanatory variables on unadjusted and adjusted incidence rate ratios

There was a significant negative interaction between individual level non-white ethnic minority status and the proportion of non-white ethnic minorities at neighbourhood level (chi 2=3.9, df=1, P<0.05). Thus the analysis, stratified by thirds of proportion of non-white ethnic minorities, revealed that as the proportion in a given population decreased, the rate of schizophrenia in non-white ethnic minorities increased (table 3). Indeed, there was a "dose-response" relation with increasing incidence in non-white ethnic minorities as the proportion of such minorities in an area fell.


                              
View this table:
[in this window]
[in a new window]
 

Table 3. Change in incidence and incidence rate ratios for research diagnostic criteria for schizophrenia according to operational checklist for psychotic disorders with proportion of ethnic minority




    Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References

Our data show an inverse dose-response relation between the proportion of people from a non-white ethnic minority group living in an area and their incidence rate for schizophrenia.

Methodological issues
The strengths of our study are that all psychiatric contacts were included (not just admissions) and that diagnostic objectivity was maximised by using computer generated diagnoses. There were, however, concurrent weaknesses. We assumed that all people with schizophrenia will come into contact with the psychiatric services. If there was differential ascertainment across wards, this could have affected the results. We took care to estimate the ward level populations as accurately as possible, but if differential underenumeration between wards had occurred during the census, this could have biased the results, although not necessarily in the direction of our findings. Our study was a retrospective case record study, but clinical staff rotated through jobs that covered the different electoral wards. Our results would have been biased only if case notes were recorded differently for different electoral wards, and this is unlikely. Finally, our methods could be criticised because the white group contained individuals from white ethnic minority groups, most of whom were born in the Republic of Ireland.

Previous findings
Our results are consistent with those from studies in the United States that have found an inverse correlation between an individual's risk of mental illness and the relative proportion of their ethnic group living in an area. 11 21 22 Cochrane and Bal calculated first and total admission rates for schizophrenia for the whole of England in 1981 for 15 different ethnic groups on the basis of place of birth.12 Their analysis between and within groups did not find that rates increased as the relative size of the ethnic group decreased, with the exception that there was a strong significant negative correlation (-0.86, P<0.01) between admission rates for schizophrenia and relative size of the population born in the Republic of Ireland.

Unlike other studies, we used incidence data rather than data on hospital admission. Moreover, we were able to look at smaller areas that have less variance in coverage and access to services and used appropriate multilevel statistical techniques.

Interpretation
Our results could be due to selection bias in that people who choose to live in areas where they are more isolated from their own ethnic community, perhaps during a prodromal period, could be more at risk of developing schizophrenia. This seems unlikely as only limited choice is possible because most housing in Camberwell is local authority (public) housing.

Our results could be confounded by economic deprivation. We have tried to control for this, but there still could have been an uncontrolled effect if the non-white people living in predominantly white areas were more deprived than those in areas with a higher proportion of non-white people. We believe that this is unlikely because the wards with the highest proportion of non-white people are extremely and uniformly deprived to a level not reached anywhere in the mainly white neighbourhoods.

To invalidate our results any confounder, such as drug misuse or presence of a particularly high risk group, would have to act differentially across neighbourhoods, exerting maximum effect in neighbourhoods with a low proportion of non-white ethnic minorities, less effect on those with medium proportion, and least effect on those with a high proportion.

Mechanism
Our findings point towards there being a social risk factor for the increased rate of schizophrenia reported in non-white ethnic minorities in the United Kingdom. What seems to be important is the absolute number or concentration of people from non-white ethnic groups in the immediate vicinity. Thus, a possible mechanism is increased exposure to, and/or reduced protection against, stress and life events. Specific stresses for people in ethnic minority groups could be overt discrimination, institutionalised racism, and perceived alienation, isolation, and anomie.23 The more isolated a member of an ethnic minority, the more likely he or she may be to encounter such stresses.24 People from ethnic minorities may be more likely to be singled out or be more vulnerable when they are in a small minority. Reduced protection from the effects of such stresses could be due to decreased social networks or social buffers in small or dispersed ethnic minority populations.

    Acknowledgments

   Contributors: RMM, RGM, JB, and JA designed the study. JB, RG, and JvO collected the data. KM, JB, and JvO discussed the analysis, which was carried out by JvO. JB, JvO, KM, RG, and RGM discussed and interpreted the results. The paper was written by JB, KM, JvO, and RMM. JB is the guarantor for the paper.

    Footnotes

Funding: JB was supported by the Stanley Foundation and the Gordon Small Trust.

Competing interests: None declared.


    References
Top
Abstract
Introduction
Methods
Results
Discussion
References

1. Harrison G, Owens D, Holton A, Neilson D, Boot D. A prospective study of severe mental disorder in Afro-Caribbean patients. Psychol Med 1988; 18: 643-657[Medline].
2. Wessely S, Castle D, Der G, Murray R. Schizophrenia and Afro-Caribbeans. A case-control study. Br J Psychiatry 1991; 159: 795-801[Abstract/Free Full Text].
3. Van Os J, Castle DJ, Takei N, Der G, Murray RM. Psychotic illness in ethnic minorities: clarification from the 1991 census. Psychol Med 1996; 26: 203-208[Medline].
4. King M, Coker E, Leavey G, Hoare A, Johnson-Sabine E. Incidence of psychotic illness in London: comparison of ethnic groups. BMJ 1994; 309: 1115-1119[Abstract/Free Full Text].
5. Bhugra D, Leff J, Mallett R, Der G, Corridan B, Rudge S. Incidence and outcome of schizophrenia in whites, African-Caribbeans and Asians in London. Psychol Med 1997; 27: 791-798[CrossRef][Medline].
6. McKenzie K, Van Os J, Fahy T, Jones P, Harvey I, Toone B, et al. Psychosis with good prognosis in Afro-Caribbean people now living in the United Kingdom. BMJ 1995; 311: 1325-1328[Abstract/Free Full Text].
7. Hutchinson G, Takei N, Fahy TA, Bhugra D, Gilvarry C, Moran P, et al. Morbid risk of schizophrenia in first-degree relatives of white and African-Caribbean patients with psychosis. Br J Psychiatry 1996; 169: 776-780[Abstract/Free Full Text].
8. Hutchinson G, Takei N, Bhugra D, Fahy TA, Gilvarry C, Mallett R, et al. Increased rate of psychosis among African-Caribbeans in Britain is not due to an excess of pregnancy and birth complications. Br J Psychiatry 1997; 171: 145-147[Abstract/Free Full Text].
9. Hutchinson G, Mallett R, Fletcher H. Are the increased rates of psychosis reported for the population of Caribbean origin in Britain an urban effect? Int Rev Psychiatry 1999; 11: 122-128[CrossRef].
10. Sharpley MS, Hutchinson G, Murray RM, McKenzie K. Understanding the excess of psychosis among the African-Caribbean population in England: review of current hypotheses. Br J Psychiatry 2001; 178(suppl 40): 60-68[CrossRef].
11. Halpern D. Minorities and mental health. Soc Sci Med 1993; 36: 597-607.
12. Cochrane R, Bal SS. Ethnic density is unrelated to incidence of schizophrenia. Br J Psychiatry 1988; 153: 363-366[Abstract/Free Full Text].
13. McGuffin P, Farmer A, Harvey I. A polydiagnostic application of operational criteria in studies of psychotic illness. Development and reliability of the OPCRIT system. Arch Gen Psychiatry 1991; 48: 764-770[Abstract/Free Full Text].
14. Spitzer RL, Endicott J, Robins E. Research diagnostic criteria: rationale and reliability. Arch Gen Psychiatry 1978; 35: 773-782[Abstract/Free Full Text].
15. Wing JK, Cooper JE, Sartorius N. The measurement and classification of psychiatric symptoms. London: Cambridge University Press, 1974.
16. Williams J, Farmer AE, Arkenheil M, Kaufmann CA, McGuffin P. A multi-centre inter-rater reliability study using the OPCRIT computerized diagnostic system. Psychol Med 1996; 26: 775-783[Medline].
17. Castle D, Wessely S, Der G, Murray RM. The incidence of operationally defined schizophrenia in Camberwell, 1965-84. Br J Psychiatry 1991; 159: 790-794[Abstract/Free Full Text].
18. Office of Population Census and Surveys Population Estimates Unit. 1991 census, Local base statistics. London: Office for National Statistics, 1991.
19. London Research Centre. Round projections and methodology. London: London Research Centre, 1997.
20. Department of the Environment. Index of local conditions. London: Office for National Statistics, 1991.
21. Rabkin J. Ethnic density and psychiatric hospitalization: hazards of minority status Am J Psychiatry 1979; 136: 1562-1566[Abstract/Free Full Text].
22. Murphy HBM. Migration and the major mental disorders: a reappraisal. In: Kantor M, ed. Proceedings of the fifth annual conference on community mental health research. Springfield, IL: Charles C Thomas, 1965:5-28.
23. Williams D. Racism and health: a research agenda. Ethn Dis 1996; 6: 1-6[Medline].
24. King G, Williams DR. Race and health a multi-dimensional approach to African-American health. In: Amik BC, III,Levins S, Tarlov AR, Chapman Walsh D, eds. Society and health. New York: Oxford University Press, 1995:93-130.

(Accepted 29 August 2001)

© BMJ 2001
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to StumbleUpon StumbleUpon   Add to Technorati Technorati    What's this?

Relevant Articles

Schizophrenia
Marco M Picchioni and Robin M Murray
BMJ 2007 335: 91-95. [Extract] [Full Text] [PDF]

Schizophrenia in ethnic minority groups
Dirk Jacobs, J Boydell, and R M Murray
BMJ 2002 324: 916. [Extract] [Full Text]

Schizophrenia in ethnic minorities is more common in white neighbourhoods
BMJ 2001 323: 0. [Full Text]

This article has been cited by other articles:

  • Anbesse, B., Hanlon, C., Alem, A., Packer, S., Whitley, R. (2009). Migration and Mental Health: a Study of Low-Income Ethiopian Women Working in Middle Eastern Countries. Int J Soc Psychiatry 55: 557-568 [Abstract]  
  • Kirkbride, J B, Croudace, T, Brewin, J, Donoghue, K, Mason, P, Glazebrook, C, Medley, I, Harrison, G, Cooper, J E, Doody, G A, Jones, P B (2009). Is the incidence of psychotic disorder in decline? Epidemiological evidence from two decades of research. Int J Epidemiol 38: 1255-1264 [Abstract] [Full text]  
  • Stafford, M., Becares, L., Nazroo, J. (2009). Objective and Perceived Ethnic Density and Health: Findings From a United Kingdom General Population Survey. Am J Epidemiol 170: 484-493 [Abstract] [Full text]  
  • Cromby, J., Harper, D. J. (2009). Paranoia: A Social Account. Theory Psychology 19: 335-361 [Abstract]  
  • Veling, W., Hoek, H. W., Wiersma, D., Mackenbach, J. P. (2009). Ethnic Identity and the Risk of Schizophrenia in Ethnic Minorities: A Case-Control Study. Schizophr Bull 0: sbp032v1-sbp032 [Abstract] [Full text]  
  • Corcoran, C., Perrin, M., Harlap, S., Deutsch, L., Fennig, S., Manor, O., Nahon, D., Kimhy, D., Malaspina, D., Susser, E. (2009). Incidence of Schizophrenia Among Second-Generation Immigrants in the Jerusalem Perinatal Cohort. Schizophr Bull 35: 596-602 [Abstract] [Full text]  
  • Pilgrim, D., Rogers, A., Bentall, R. (2009). The centrality of personal relationships in the creation and amelioration of mental health problems: the current interdisciplinary case. Health (London) 13: 235-254 [Abstract]  
  • Mckenzie, K. (2008). Urbanization, Social Capital and Mental Health. Global Social Policy 8: 359-377 [Abstract]  
  • Bhavsar, V., Bhugra, D. (2008). Globalization: Mental Health and Social Economic Factors. Global Social Policy 8: 378-396 [Abstract]  
  • March, D., Hatch, S. L., Morgan, C., Kirkbride, J. B., Bresnahan, M., Fearon, P., Susser, E. (2008). Psychosis and Place. Epidemiol Rev 30: 84-100 [Abstract] [Full text]  
  • Coid, J. W., Kirkbride, J. B., Barker, D., Cowden, F., Stamps, R., Yang, M., Jones, P. B. (2008). Raised Incidence Rates of All Psychoses Among Migrant Groups: Findings From the East London First Episode Psychosis Study. Arch Gen Psychiatry 65: 1250-1258 [Abstract] [Full text]  
  • Bentall, R. P., Fernyhough, C. (2008). Social Predictors of Psychotic Experiences: Specificity and Psychological Mechanisms. Schizophr Bull 34: 1012-1020 [Abstract] [Full text]  
  • van Os, J., Rutten, B. P., Poulton, R. (2008). Gene-Environment Interactions in Schizophrenia: Review of Epidemiological Findings and Future Directions. Schizophr Bull 34: 1066-1082 [Abstract] [Full text]  
  • Walters, P., Ashworth, M., Tylee, A. (2008). Ethnic density, physical illness, social deprivation and antidepressant prescribing in primary care: ecological study. Br. J. Psychiatry 193: 235-239 [Abstract] [Full text]  
  • Kirkbride, J. B., Barker, D., Cowden, F., Stamps, R., Yang, M., Jones, P. B., Coid, J. W. (2008). Psychoses, ethnicity and socio-economic status. Br. J. Psychiatry 193: 18-24 [Abstract] [Full text]  
  • Bhui, K, Khatib, Y, Viner, R, Klineberg, E, Clark, C, Head, J, Stansfeld, S (2008). Cultural identity, clothing and common mental disorder: a prospective school-based study of white British and Bangladeshi adolescents. J. Epidemiol. Community Health 62: 435-441 [Abstract] [Full text]  
  • Stone, L., Finlay, W.M.L. (2008). A Comparison of African-Caribbean and White European Young Adults' Conceptions of Schizophrenia Symptoms and the Diagnostic Label. Int J Soc Psychiatry 54: 242-261 [Abstract]  
  • Yoder, M. (2008). Helping in the Wake of Disaster: A Graduate Student's Perspective in the Aftermath of the VT Tragedy. Traumatology 14: 25-31 [Abstract]  
  • Veling, W., Susser, E., van Os, J., Mackenbach, J. P., Selten, J.-P., Hoek, H. W. (2008). Ethnic Density of Neighborhoods and Incidence of Psychotic Disorders Among Immigrants. Am. J. Psychiatry 165: 66-73 [Abstract] [Full text]  
  • SELTEN, J.-P., CANTOR-GRAAE, E. (2007). Hypothesis: social defeat is a risk factor for schizophrenia?. Br. J. Psychiatry 191: s9-s12 [Abstract] [Full text]  
  • MENEZES, P. R., SCAZUFCA, M., BUSATTO, G. F., COUTINHO, L. M. S., McGUIRE, P. K., MURRAY, R. M. (2007). Incidence of first-contact psychosis in Sao Paulo, Brazil. Br. J. Psychiatry 191: s102-s106 [Abstract] [Full text]  
  • Veling, W., Selten, J.-P., Susser, E., Laan, W., Mackenbach, J. P, Hoek, H. W (2007). Discrimination and the incidence of psychotic disorders among ethnic minorities in The Netherlands. Int J Epidemiol 36: 761-768 [Abstract] [Full text]  
  • Picchioni, M. M, Murray, R. M (2007). Schizophrenia. BMJ 335: 91-95 [Full text]  
  • Allardyce, J., Boydell, J. (2006). Environment and Schizophrenia: Review: The Wider Social Environment and Schizophrenia. Schizophr Bull 32: 592-598 [Abstract] [Full text]  
  • Whitley, R., Prince, M., McKenzie, K., Stewart, R. (2006). Exploring the Ethnic Density Effect: A Qualitative Study of a London Electoral Ward. Int J Soc Psychiatry 52: 376-391 [Abstract]  
  • Fearon, P., Morgan, C. (2006). Environmental Factors in Schizophrenia: The Role of Migrant Studies. Schizophr Bull 32: 405-408 [Abstract] [Full text]  
  • Krause, I.-B. (2006). Hidden Points of View in Cross-cultural Psychotherapy and Ethnography.. Transcultural Psychiatry 43: 181-203 [Abstract]  
  • Wicks, S., Hjern, A., Gunnell, D., Lewis, G., Dalman, C. (2005). Social Adversity in Childhood and the Risk of Developing Psychosis: A National Cohort Study. Am. J. Psychiatry 162: 1652-1657 [Abstract] [Full text]  
  • Whitley, R. (2005). Book Review: Cultural Diversity, Mental Health and Psychiatry: The Struggle Against Racism. Transcultural Psychiatry 42: 507-509  
  • Bhui, K., Stansfeld, S., Head, J., Haines, M., Hillier, S., Taylor, S., Viner, R., Booy, R. (2005). Cultural identity, acculturation, and mental health among adolescents in east London's multiethnic community. J. Epidemiol. Community Health 59: 296-302 [Abstract] [Full text]  
  • Henderson, C., Diez Roux, A. V, Jacobs, D. R Jr, Kiefe, C. I, West, D., Williams, D. R (2005). Neighbourhood characteristics, individual level socioeconomic factors, and depressive symptoms in young adults: the CARDIA study. J. Epidemiol. Community Health 59: 322-328 [Abstract] [Full text]  
  • Weich, S. (2005). Absence of spatial variation in rates of the common mental disorders. J. Epidemiol. Community Health 59: 254-257 [Full text]  
  • Cantor-Graae, E., Selten, J.-P. (2005). Schizophrenia and Migration: A Meta-Analysis and Review. Am. J. Psychiatry 162: 12-24 [Abstract] [Full text]  
  • Harland, R., Morgan, C., Hutchinson, G. (2004). Phenomenology, science and the anthropology of the self: a new model for the aetiology of psychosis. Br. J. Psychiatry 185: 361-362 [Full text]  
  • Muntaner, C., Eaton, W. W., Miech, R., O'Campo, P. (2004). Socioeconomic Position and Major Mental Disorders. Epidemiol Rev 26: 53-62 [Full text]  
  • Bhugra, D. (2004). Migration, distress and cultural identity. Br Med Bull 69: 129-141 [Abstract] [Full text]  
  • Knapp, M., King, D., Pugner, K., Lapuerta, P. (2004). Non-adherence to antipsychotic medication regimens: associations with resource use and costs. Br. J. Psychiatry 184: 509-516 [Abstract] [Full text]  
  • Kelly, B. D. (2003). Globalisation and psychiatry. Adv. Psychiatr. Treat. 9: 464-470 [Abstract] [Full text]  
  • Holloway, F., Aitchison, K. (2003). Early intervention in psychosis: from Government prescription to clinical practice. Psychiatr. Bull. 27: 243-244 [Full text]  
  • van Os, J., McGuffin, P. (2003). Can the social environment cause schizophrenia?. Br. J. Psychiatry 182: 291-292 [Full text]  
  • NEELEMAN, J. (2003). The relativity of relative risks: disadvantage or opportunity?. Br. J. Psychiatry 182: 101-102 [Full text]  
  • JANSSEN, I., HANSSEN, M., BAK, M., BIJL, R. V., DE GRAAF, R., VOLLEBERGH, W., McKENZIE, K., VAN OS, J. (2003). Discrimination and delusional ideation. Br. J. Psychiatry 182: 71-76 [Abstract] [Full text]  
  • Eagles, J. M. (2003). Racial discrimination and mental illness. Br. J. Psychiatry 182: 77-77 [Full text]  
  • Freeman, H., McKenzie, K., Chakraborty, A. (2003). Racial discrimination and mental illness * Authors' reply. Br. J. Psychiatry 182 : 77-79 [Full text]  
  • McKENZIE, K., WHITLEY, R., WEICH, S. (2002). Social capital and mental health. Br. J. Psychiatry 181: 280-283 [Full text]  
  • CHAKRABORTY, A., McKENZIE, K. (2002). Does racial discrimination cause mental illness?. Br. J. Psychiatry 180: 475-477 [Full text]  
  • Jacobs, D., Boydell, J, Murray, R M (2002). Schizophrenia in ethnic minority groups. BMJ 324: 916-916 [Full text]  

Rapid Responses:

Read all Rapid Responses

Home alone? More information is needed regarding the residential location of the parents.
Danny Koren
bmj.com, 8 Dec 2001 [Full text]
Can selection bias in prevalence data really be ruled out?
Dirk Jacobs
bmj.com, 10 Dec 2001 [Full text]
Home alone - Black/White? Blue/Orange?
Annie Heaton
bmj.com, 10 Dec 2001 [Full text]
Affirmation of Anecdotal Knowledge
Adria Armbrister
bmj.com, 11 Dec 2001 [Full text]
Incidence of schizophrenia in ethnic minorities in London: the challenges of ecological studies.
Oyedeji Ayonrinde, et al.
bmj.com, 18 Dec 2001 [Full text]
Incidence of schizophrenia in ethnic minorities in London
JOHN M EAGLES
bmj.com, 20 Dec 2001 [Full text]
Finding lack validity.
Rajesh P. Moholkar, et al.
bmj.com, 27 Dec 2001 [Full text]
Risks in ecological study of ethnicity
Mark R D Johnson
bmj.com, 15 Jan 2002 [Full text]
Response by two of the authors
Kwame J McKenzie, et al.
bmj.com, 6 Feb 2002 [Full text]
Access jobs at BMJ Careers
Whats new online at Student BMJ