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Early Intervention in Psychiatry 2015; 9: 61–65
doi:10.1111/eip.12106
Brief Report Migrant background and ethnic minority status as predictors for duration of untreated psychosis Mari Nerhus, Akiah Ottesen Berg, Marit Haram, Levi Røstad Kvitland, Ole Andreas Andreassen and Ingrid Melle Abstract
Division of Mental Health and Addiction, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, KG Jebsen Centre for Psychosis Research, Oslo, Norway Corresponding author: Dr Ingrid Melle, KG Jebsen Centre for Psychosis Research Ullevaal Hospital Building 49, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway. Email: [email protected] Received 5 June 2013; accepted 10 October 2013
Aim: The aim of the study was to explore if patients with migration and/or ethnic minority background have longer duration of untreated psychosis (DUP) than patients from the reference population, and in case to what extent this was best explained by ethnic minority status or migration background, including age at migration. Methods: Four hundred sixty-two first-episode patients were included. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis
Results: Being part of an ethnic minority group had a trend-level significance, and migration after the age of 6 had a statistically significant association with prolonged DUP. Conclusions: Age at migration has a moderate, but statistically significant effect on DUP. The findings indicate migrating after school start is associated with a longer DUP in immigrant populations.
Key words: early diagnosis, health care, immigrants, minority groups, psychosis.
INTRODUCTION Being an immigrant or being part of an ethnic minority population, clearly distinct from the majority population, is well-established risk factors for psychotic disorders.1,2 Ethnic minority status and a migrant background also have implications for pathways into the health-care system and, thus, have possible associations with the duration of untreated psychosis (DUP).3–5 A long DUP has consistently been shown to be associated with poorer outcome.6,7 An insidious mode of onset,8 early age at onset,9 poor premorbid adjustment and a diagnosis within the schizophrenia spectrum,10 living in highly urbanized areas4 or lack of close family relations, and infrequent family and social contacts have previously also been found to be associated with long DUP.11–13 Findings regarding DUP’s relation to ethnic minority status and migrant background are however ambiguous. A Dutch study focusing on ethnic minority status found significantly longer © 2013 Wiley Publishing Asia Pty Ltd
I Disorders was used for diagnostic purposes. Patients were interviewed about migration history and ethnicity using structured questionnaires.
DUP in minorities than in the reference population.3 In the UK-based AESOP (Aetiology and Ethnicity in Schizophrenia and Other Psychoses) cohort, black African patients had shorter DUP than the reference population,5 whereas no ethnicitybased differences in DUP was found in a Canadian study.14 A predominantly African-American group with economic disadvantages from the USA had significantly longer DUP than other patients.15 A second Dutch study, focusing on migration background, found longer DUP in first-generation immigrants.4 In a non-systematic review, immigrants tended to be unfamiliar with the local health-care system in terms of navigating services needed.16 Patients who recently migrated will probably have even less knowledge about local health service access. To what extent cultural beliefs about mental disorders and right to access health services may influence help-seeking behaviour could also vary based on local service organization. The effects on DUP of ethnic minority status versus migration can be 61
Migration and duration of untreated psychosis difficult to evaluate as ethnic minorities (EMs) often have a migration background. However, some EMs have a long local history whereas other groups have migrated from countries that resemble the majority and do not appear as EMs. The current study is based on a large, first-episode sample from a catchment area-based health-care system. Of the catchment area population 19.1% are first- or second-generation immigrants, and 12.0% are EMs.17 Health service access is for practical purposes without costs for the patients, making it possible to disentangle the effects of migration and ethnic minority status from the effects of economic disadvantage. We aimed to explore if patients with migration or ethnic minority background have longer DUPs than patients from the reference population, and, in case, we want to explore if this is best explained by ethnic minority status or migration background, including age at migration (before or after start of compulsory schooling at age 6).
METHOD Participants Participants were recruited consecutively between 2004 and 2012 from in- and outpatient psychiatric units in the catchment area of the five major hospitals in East Norway, as part of the larger Thematically Organized Psychosis Study, approved by the Regional Committee for Medical Research Ethics. Our research methodology conformed to the Code of Ethics of the World Medical Association, Helsinki Declaration. A total of 462 patients with reliable DUP measurements gave informed consent to participate: 250 with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) schizophrenia spectrum disorders and 212 with other psychotic disorders. A pronounced cognitive deficiency (IQ below 70), severe brain damage or the inability to speak a Scandinavian language, were exclusion criteria. The participants included 312 non-immigrants (NI) and 150 (32.5%) immigrants (defined as foreign born or children of foreign born); 50 (10.8%) originated from Europe, North America and Oceania, and were categorized as migrants from the ethnic majority (MM); 100 (21.6%) had cultural background from Africa, Asia (including Arabic countries) or Latin America, and were categorized as EMs. 62
Assessments All patients were assessed by trained clinical research personnel. The Structured Clinical Interview for DSM-IV Axis I Disorders was used for diagnostic purposes. Interrater reliability had an overall kappa score of 0.77 (95% confidence interval: 0.60– 0.94).18 Premorbid adjustment was assessed by the Premorbid Adjustment Scale (PAS).19 Patients were interviewed about migration history and ethnicity, and data were also collected about education, occupation, housing and marital status. DUP was defined as the period of time from first psychotic symptom (i.e. four or more on Positive and Negative Syndrome Scale for Schizophrenia20 items P1, P3, P5, P6 or G9 for 1 week), until adequate treatment (i.e. admission to hospital or antipsychotic medication in adequate doses). Statistics Statistical analysis was performed using IBM Statistical Package for the Social Sciences 20 (IBM Corp., Armonk, NY, USA). The level of significance was preset to P < 0.05 (two tailed). One-way analyses of variance with Tukey’s post hoc tests were used for group-wise comparisons of continuous variables and chi-square test for categorical variables. Bivariate correlations were used to explore association between background variables and DUP, migration background and ethnic minority status, respectively. Hierarchical, blockwise and multiple regression analyses were used to assess the influence of migration background and ethnic minority status on DUP, after controlling for possible confounding variables, with premorbid academic and social adjustment in the first block; age at onset and diagnosis in the second; and ethnic minority status, migration and age at migration, respectively, at the last step. PAS and DUP measures were skewed and logarithmic transformed for the analyses. Total years of education and PAS academic score were correlated (r = −0.41, P < 0.001) and could not be entered simultaneously. Because differences in total years of education could be based on different school systems in countries of origin and thus dependent on migration status, the PAS score was preferred in the final model. Age and age at onset was highly correlated (r = 0.86, P < 0.001) in this first-episode sample, and age at onset was kept in the final analyses. All nonsignificant variables (including close family relations and gender) were taken out of the final models. Only the final models are presented in the paper. Missing values (three for age at migration and nine for PAS) were replaced by group mean. The variable © 2013 Wiley Publishing Asia Pty Ltd
M. Nerhus et al. TABLE 1. Demographic information for total sample and for immigration based subgroups NI (n = 312)
Age Age at onset Premorbid academic adjustment† Premorbid social adjustment† Total years of education
Preschool age at migration Male Schizophrenia diagnosis Close family relations‡
Immigrants (n = 150)
ANOVA
with Tukey’s posthoc test
Mean (SD)
MM (n = 50) Mean (SD)
EM (n = 100) Mean (SD)
27.0 (8.2) 24.0 (8.3) 1.14 (0.46)
28.1 (9.4) 23.5 (10.0) 0.98 (0.45)
27.2 (7.8) 24.5 (7.3) 1.17 (0.43)
P = 0.64 P = 0.77 P = 0.04
0.92 (0.57)
0.93 (0.56)
0.88 (0.59)
P = 0.76
13.1 (2.5)
13.1 (3.1)
11.5 (2.9)
P < 0.001
n (%) –
n (%) 29 (58.0)
n (%) 47 (47.0)
Chi-square P = 0.20
184 (59.0) 163 (52.2) 148 (47.4)
28 (56.0) 25 (50.0) 17 (34.0)
65 (65.0) 62 (62.0) 54 (54.0)
P = 0.47 P = 0.19 P = 0.07
EM > MM (P = 0.05)
EM < MM, NI (P = 0.003/0.001)
†High score means low function. ‡Living with spouse or parents. ANOVA, analysis of variance; EM, ethnic minority; MM, migrant majority; NI, non-immigrants; SD, standard deviation.
age at migration was dichotomized to migration before or after the age of 6, that is, start of school. Model fit was evaluated through examination of residual plots. RESULTS The EM group had poorer academic adjustment than the MM group, and shorter education than both the MM and NI groups (Table 1). Age at onset, premorbid social and academic adjustment, and schizophrenia diagnosis were all significantly associated with DUP (Pearson’s r = −0.17 to 0.25; P < 0.001). There were no significant associations between premorbid academic or social adjustment and EM status (Pearson’s r = 0.05 and −0.03, respectively; P = 0.48). In the multivariate regression analyses, age at onset, premorbid social and academic adjustment, and schizophrenia diagnosis retained a significant influence on DUP. In the last block, neither migration per se (P = 0.10; data not shown) nor being part of the EM group (P = 0.07) had a statistically significant association with DUP (Table 2). Migration after the age of 6 (Table 3) had a statistically significant association with DUP.
associated with a longer DUP in a catchment areabased public health-care system. Consistent with previous studies,10 we also found that poor premorbid adjustment, low age at onset and diagnosis within the schizophrenia spectrum were associated with a longer DUP. We propose that migration after school start may influence knowledge about the local health-care system and thus help-seeking behaviour in immigrants’ low levels of literacy in general adds barriers to using and assessing mental health services,21 and low levels of mental health literacy in particular have been found to delay treatment for depression in immigrants.22 Low mental health literacy may thus partially mediate the association between low premorbid academic adjustment and shorter education with longer DUP, two characteristics that were significantly more compromised in EM. This should be the focus of future research concerning the treatment and outcome of psychotic disorders in immigrant groups. Another important factor may be culturally rooted stigma of visiting a psychiatrist,23 which could explain why ethnic minority status appears to have an effect on DUP regardless of age at migration.3,4 Strengths and limitations
DISCUSSION The main finding of this study is that migration after the age of 6 and ethnic minority status were © 2013 Wiley Publishing Asia Pty Ltd
We did not include patients who needed an interpreter, and we may have missed very recent immigrants in our sample. We cannot rule out that other factors associated with both EM status and 63
Migration and duration of untreated psychosis TABLE 2. Hierarchical blockwise multiple regression model of variables predicting duration of untreated psychosis including ethnic minority status (EM) variable Unstandardized coefficients B Block 1: Academic Social Block 2: Age at onset Schizophrenia diagnosis Block 3: EM
Standardized coefficients β
SE
t
95% confidence interval for B
Sig.
Lower
Upper
R2 change
0.323 0.380
0.189 0.147
0.080 0.120
1.714 2.576
0.087 0.010
−0.047 0.090
0.694 0.670
0.057
−0.031 −0.693
0.010 0.164
−0.140 −0.192
−3.046 −4.230
0.002 0.000
−0.050 −1.016
−0.011 −0.371
0.059
0.355
0.193
0.081
1.837
0.067
−0.025
0.734
0.007
Total adjusted R2 = 0.112; total model F = 12.649, sig. = 0.000. SE, standard error.
TABLE 3. Hierarchical blockwise multiple regression model of variables predicting duration of untreated psychosis including preschool age at migration variable Unstandardized coefficients B Block 1: Academic Social Block 2: Age at onset Schizophrenia diagnosis Block 3: Preschool age at migration
SE
Standardized coefficients β
t
Sig.
95% confidence interval for B Lower
Upper
R2 change
0.381 0.381
0.188 0.147
0.095 0.120
2.021 2.594
0.044 0.010
0.010 0.092
0.751 0.670
0.057
−0.033 −0.684
0.010 0.163
−0.150 −0.189
−3.254 −4.187
0.001 0.000
−0.052 −1.005
−0.013 −0.363
0.059
−0.538
0.219
−0.110
−2.460
0.014
−0.968
−0.108
0.012
Total adjusted R2 = 0.117; total model F = 13.254, sig. = 0.000. SE, standard error.
help-seeking behaviour, such as language skills, could confound the DUP results; however, all participants in our sample did speak a Scandinavian language fluently. The rate of EMs in the current sample is at the same level as in the general population, and previous findings of equal rates of admissions24 and consultations25 because of mental illnesses in both EMs and the reference population in this catchment area indicate that findings can be generalized.
ACKNOWLEDGEMENTS
CONCLUSION
REFERENCES
Age at migration has a moderate, but statistically significant effect on DUP. The findings indicate that migrating after school start is associated with a longer DUP in immigrant population. 64
The study was supported by the Research Council of Norway, Regional Health Authority South Eastern Norway, Oslo University Hospital and the University of Oslo. We declare that none of the authors are financially involved or affiliated with any organization that may benefit from these findings. We thank all participants to the TOP study for their contribution as well as all of our colleagues who have recruited and interviewed participants to the study.
1. Bourque F, van der Ven E, Malla A. A meta-analysis of the risk for psychotic disorders among first- and second-generation immigrants. Psychol Med 2011; 41: 897–910. 2. Cantor-Graae E, Selten JP. Schizophrenia and migration: a meta-analysis and review. Am J Psychiatry 2005; 162: 12–24. © 2013 Wiley Publishing Asia Pty Ltd
M. Nerhus et al. 3. Sterk B, Slief EM, Blankers M, Linszen DH, de Haan L. Duration of untreated psychosis and ethnicity. Schizophr Res 2010; 124: 238–9. 4. Boonstra N, Sterk B, Wunderink L, Sytema S, De Haan L, Wiersma D. Association of treatment delay, migration and urbanicity in psychosis. Eur Psychiatry 2012; 27: 500–5. 5. Morgan C, Fearon P, Hutchinson G et al. Duration of untreated psychosis and ethnicity in the AESOP first-onset psychosis study. Psychol Med 2006; 36: 239–47. 6. Marshall M, Lewis S, Lockwood A, Drake R, Jones P, Croudace T. Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Arch Gen Psychiatry 2005; 62: 975–83. 7. Chang WC, Tang JY, Hui CL et al. Duration of untreated psychosis: relationship with baseline characteristics and three-year outcome in first-episode psychosis. Psychiatry Res 2012; 198: 360–5. 8. Compton MT, Chien VH, Leiner AS, Goulding SM, Weiss PS. Mode of onset of psychosis and family involvement in helpseeking as determinants of duration of untreated psychosis. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 975–82. 9. Ehmann TS, Tee KA, Macewan GW et al. Treatment delay and pathways to care in early psychosis. Early Interv Psychiatry 2013. doi: 10.1111/eip.12051 10. Bechard-Evans L, Schmitz N, Abadi S, Joober R, King S, Malla A. Determinants of help-seeking and system related components of delay in the treatment of first-episode psychosis. Schizophr Res 2007; 96: 206–14. 11. Melle I, Haahr U, Friis S et al. Reducing the duration of untreated first-episode psychosis – effects on baseline social functioning and quality of life. Acta Psychiatr Scand 2005; 112: 469–73. 12. Goulding SM, Leiner AS, Thompson NJ, Weiss PS, Kaslow NJ, Compton MT. Family strengths: a potential determinant of the duration of untreated psychosis among hospitalized African-American first-episode patients. Early Interv Psychiatry 2008; 2: 162–8. 13. Morgan C, Dazzan P, Morgan K et al. First episode psychosis and ethnicity: initial findings from the AESOP study. World Psychiatry 2006; 5: 40–6.
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14. van der Ven E, Bourque F, Joober R, Selten JP, Malla AK. Comparing the clinical presentation of first-episode psychosis across different migrant and ethnic minority groups in Montreal, Quebec. Can J Psychiatry 2012; 57: 300– 8. 15. Compton MT, Ramsay CE, Shim RS et al. Health services determinants of the duration of untreated psychosis among African-American first-episode patients. Psychiatr Serv 2009; 60: 1489–94. 16. Lindert J, Schouler-Ocak M, Heinz A, Priebe S. Mental health, health care utilisation of migrants in Europe. Eur Psychiatry 2008; 23 (Suppl. 1): 14–20. 17. Statstics Norway. Immigrants and Norwegian-born to immigrant parents. [Cited 2010.] Available from URL: http:// www.ssb.no/ 18. Ringen PA, Melle I, Birkenaes AB et al. The level of illicit drug use is related to symptoms and premorbid functioning in severe mental illness. Acta Psychiatr Scand 2008; 118: 297– 304. 19. Cannon-Spoor HE, Potkin SG, Wyatt RJ. Measurement of premorbid adjustment in chronic schizophrenia. Schizophr Bull 1982; 8: 470–84. 20. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987; 13: 261–76. 21. Grace GD, Christensen RC. Literacy and mental health care. Psychiatr Serv 1998; 49: 7. 22. Gabriel AV, Violato C. Depression literacy among patients and the public: a literature review. Prim Psychiatry 2010; 17: 55–64. 23. Sadeghieh Ahari S, Nikpou H, Molavi P, Abdi R, Amani F, Shirinzadeh B. An investigation of duration of untreated psychosis and the affecting factors. J Psychiatr Ment Health Nurs 2013. doi: 10.1111/jpm.12067 24. Berg JE, Johnsen E. Are immigrants admitted to emergency psychiatric departments more often than ethnic Norwegians? Tidsskr Nor Laegeforen 2004; 124: 634–6. 25. Ayazi T, Bogwald KP. Immigrants’ use of out-patient psychiatric services. Tidsskr Nor Laegeforen 2008; 128: 162–5.
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Early Intervention in Psychiatry 2015; 9: 61–65
doi:10.1111/eip.12106
Brief Report Migrant background and ethnic minority status as predictors for duration of untreated psychosis Mari Nerhus, Akiah Ottesen Berg, Marit Haram, Levi Røstad Kvitland, Ole Andreas Andreassen and Ingrid Melle Abstract
Division of Mental Health and Addiction, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, KG Jebsen Centre for Psychosis Research, Oslo, Norway Corresponding author: Dr Ingrid Melle, KG Jebsen Centre for Psychosis Research Ullevaal Hospital Building 49, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway. Email: [email protected] Received 5 June 2013; accepted 10 October 2013
Aim: The aim of the study was to explore if patients with migration and/or ethnic minority background have longer duration of untreated psychosis (DUP) than patients from the reference population, and in case to what extent this was best explained by ethnic minority status or migration background, including age at migration. Methods: Four hundred sixty-two first-episode patients were included. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis
Results: Being part of an ethnic minority group had a trend-level significance, and migration after the age of 6 had a statistically significant association with prolonged DUP. Conclusions: Age at migration has a moderate, but statistically significant effect on DUP. The findings indicate migrating after school start is associated with a longer DUP in immigrant populations.
Key words: early diagnosis, health care, immigrants, minority groups, psychosis.
INTRODUCTION Being an immigrant or being part of an ethnic minority population, clearly distinct from the majority population, is well-established risk factors for psychotic disorders.1,2 Ethnic minority status and a migrant background also have implications for pathways into the health-care system and, thus, have possible associations with the duration of untreated psychosis (DUP).3–5 A long DUP has consistently been shown to be associated with poorer outcome.6,7 An insidious mode of onset,8 early age at onset,9 poor premorbid adjustment and a diagnosis within the schizophrenia spectrum,10 living in highly urbanized areas4 or lack of close family relations, and infrequent family and social contacts have previously also been found to be associated with long DUP.11–13 Findings regarding DUP’s relation to ethnic minority status and migrant background are however ambiguous. A Dutch study focusing on ethnic minority status found significantly longer © 2013 Wiley Publishing Asia Pty Ltd
I Disorders was used for diagnostic purposes. Patients were interviewed about migration history and ethnicity using structured questionnaires.
DUP in minorities than in the reference population.3 In the UK-based AESOP (Aetiology and Ethnicity in Schizophrenia and Other Psychoses) cohort, black African patients had shorter DUP than the reference population,5 whereas no ethnicitybased differences in DUP was found in a Canadian study.14 A predominantly African-American group with economic disadvantages from the USA had significantly longer DUP than other patients.15 A second Dutch study, focusing on migration background, found longer DUP in first-generation immigrants.4 In a non-systematic review, immigrants tended to be unfamiliar with the local health-care system in terms of navigating services needed.16 Patients who recently migrated will probably have even less knowledge about local health service access. To what extent cultural beliefs about mental disorders and right to access health services may influence help-seeking behaviour could also vary based on local service organization. The effects on DUP of ethnic minority status versus migration can be 61
Migration and duration of untreated psychosis difficult to evaluate as ethnic minorities (EMs) often have a migration background. However, some EMs have a long local history whereas other groups have migrated from countries that resemble the majority and do not appear as EMs. The current study is based on a large, first-episode sample from a catchment area-based health-care system. Of the catchment area population 19.1% are first- or second-generation immigrants, and 12.0% are EMs.17 Health service access is for practical purposes without costs for the patients, making it possible to disentangle the effects of migration and ethnic minority status from the effects of economic disadvantage. We aimed to explore if patients with migration or ethnic minority background have longer DUPs than patients from the reference population, and, in case, we want to explore if this is best explained by ethnic minority status or migration background, including age at migration (before or after start of compulsory schooling at age 6).
METHOD Participants Participants were recruited consecutively between 2004 and 2012 from in- and outpatient psychiatric units in the catchment area of the five major hospitals in East Norway, as part of the larger Thematically Organized Psychosis Study, approved by the Regional Committee for Medical Research Ethics. Our research methodology conformed to the Code of Ethics of the World Medical Association, Helsinki Declaration. A total of 462 patients with reliable DUP measurements gave informed consent to participate: 250 with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) schizophrenia spectrum disorders and 212 with other psychotic disorders. A pronounced cognitive deficiency (IQ below 70), severe brain damage or the inability to speak a Scandinavian language, were exclusion criteria. The participants included 312 non-immigrants (NI) and 150 (32.5%) immigrants (defined as foreign born or children of foreign born); 50 (10.8%) originated from Europe, North America and Oceania, and were categorized as migrants from the ethnic majority (MM); 100 (21.6%) had cultural background from Africa, Asia (including Arabic countries) or Latin America, and were categorized as EMs. 62
Assessments All patients were assessed by trained clinical research personnel. The Structured Clinical Interview for DSM-IV Axis I Disorders was used for diagnostic purposes. Interrater reliability had an overall kappa score of 0.77 (95% confidence interval: 0.60– 0.94).18 Premorbid adjustment was assessed by the Premorbid Adjustment Scale (PAS).19 Patients were interviewed about migration history and ethnicity, and data were also collected about education, occupation, housing and marital status. DUP was defined as the period of time from first psychotic symptom (i.e. four or more on Positive and Negative Syndrome Scale for Schizophrenia20 items P1, P3, P5, P6 or G9 for 1 week), until adequate treatment (i.e. admission to hospital or antipsychotic medication in adequate doses). Statistics Statistical analysis was performed using IBM Statistical Package for the Social Sciences 20 (IBM Corp., Armonk, NY, USA). The level of significance was preset to P < 0.05 (two tailed). One-way analyses of variance with Tukey’s post hoc tests were used for group-wise comparisons of continuous variables and chi-square test for categorical variables. Bivariate correlations were used to explore association between background variables and DUP, migration background and ethnic minority status, respectively. Hierarchical, blockwise and multiple regression analyses were used to assess the influence of migration background and ethnic minority status on DUP, after controlling for possible confounding variables, with premorbid academic and social adjustment in the first block; age at onset and diagnosis in the second; and ethnic minority status, migration and age at migration, respectively, at the last step. PAS and DUP measures were skewed and logarithmic transformed for the analyses. Total years of education and PAS academic score were correlated (r = −0.41, P < 0.001) and could not be entered simultaneously. Because differences in total years of education could be based on different school systems in countries of origin and thus dependent on migration status, the PAS score was preferred in the final model. Age and age at onset was highly correlated (r = 0.86, P < 0.001) in this first-episode sample, and age at onset was kept in the final analyses. All nonsignificant variables (including close family relations and gender) were taken out of the final models. Only the final models are presented in the paper. Missing values (three for age at migration and nine for PAS) were replaced by group mean. The variable © 2013 Wiley Publishing Asia Pty Ltd
M. Nerhus et al. TABLE 1. Demographic information for total sample and for immigration based subgroups NI (n = 312)
Age Age at onset Premorbid academic adjustment† Premorbid social adjustment† Total years of education
Preschool age at migration Male Schizophrenia diagnosis Close family relations‡
Immigrants (n = 150)
ANOVA
with Tukey’s posthoc test
Mean (SD)
MM (n = 50) Mean (SD)
EM (n = 100) Mean (SD)
27.0 (8.2) 24.0 (8.3) 1.14 (0.46)
28.1 (9.4) 23.5 (10.0) 0.98 (0.45)
27.2 (7.8) 24.5 (7.3) 1.17 (0.43)
P = 0.64 P = 0.77 P = 0.04
0.92 (0.57)
0.93 (0.56)
0.88 (0.59)
P = 0.76
13.1 (2.5)
13.1 (3.1)
11.5 (2.9)
P < 0.001
n (%) –
n (%) 29 (58.0)
n (%) 47 (47.0)
Chi-square P = 0.20
184 (59.0) 163 (52.2) 148 (47.4)
28 (56.0) 25 (50.0) 17 (34.0)
65 (65.0) 62 (62.0) 54 (54.0)
P = 0.47 P = 0.19 P = 0.07
EM > MM (P = 0.05)
EM < MM, NI (P = 0.003/0.001)
†High score means low function. ‡Living with spouse or parents. ANOVA, analysis of variance; EM, ethnic minority; MM, migrant majority; NI, non-immigrants; SD, standard deviation.
age at migration was dichotomized to migration before or after the age of 6, that is, start of school. Model fit was evaluated through examination of residual plots. RESULTS The EM group had poorer academic adjustment than the MM group, and shorter education than both the MM and NI groups (Table 1). Age at onset, premorbid social and academic adjustment, and schizophrenia diagnosis were all significantly associated with DUP (Pearson’s r = −0.17 to 0.25; P < 0.001). There were no significant associations between premorbid academic or social adjustment and EM status (Pearson’s r = 0.05 and −0.03, respectively; P = 0.48). In the multivariate regression analyses, age at onset, premorbid social and academic adjustment, and schizophrenia diagnosis retained a significant influence on DUP. In the last block, neither migration per se (P = 0.10; data not shown) nor being part of the EM group (P = 0.07) had a statistically significant association with DUP (Table 2). Migration after the age of 6 (Table 3) had a statistically significant association with DUP.
associated with a longer DUP in a catchment areabased public health-care system. Consistent with previous studies,10 we also found that poor premorbid adjustment, low age at onset and diagnosis within the schizophrenia spectrum were associated with a longer DUP. We propose that migration after school start may influence knowledge about the local health-care system and thus help-seeking behaviour in immigrants’ low levels of literacy in general adds barriers to using and assessing mental health services,21 and low levels of mental health literacy in particular have been found to delay treatment for depression in immigrants.22 Low mental health literacy may thus partially mediate the association between low premorbid academic adjustment and shorter education with longer DUP, two characteristics that were significantly more compromised in EM. This should be the focus of future research concerning the treatment and outcome of psychotic disorders in immigrant groups. Another important factor may be culturally rooted stigma of visiting a psychiatrist,23 which could explain why ethnic minority status appears to have an effect on DUP regardless of age at migration.3,4 Strengths and limitations
DISCUSSION The main finding of this study is that migration after the age of 6 and ethnic minority status were © 2013 Wiley Publishing Asia Pty Ltd
We did not include patients who needed an interpreter, and we may have missed very recent immigrants in our sample. We cannot rule out that other factors associated with both EM status and 63
Migration and duration of untreated psychosis TABLE 2. Hierarchical blockwise multiple regression model of variables predicting duration of untreated psychosis including ethnic minority status (EM) variable Unstandardized coefficients B Block 1: Academic Social Block 2: Age at onset Schizophrenia diagnosis Block 3: EM
Standardized coefficients β
SE
t
95% confidence interval for B
Sig.
Lower
Upper
R2 change
0.323 0.380
0.189 0.147
0.080 0.120
1.714 2.576
0.087 0.010
−0.047 0.090
0.694 0.670
0.057
−0.031 −0.693
0.010 0.164
−0.140 −0.192
−3.046 −4.230
0.002 0.000
−0.050 −1.016
−0.011 −0.371
0.059
0.355
0.193
0.081
1.837
0.067
−0.025
0.734
0.007
Total adjusted R2 = 0.112; total model F = 12.649, sig. = 0.000. SE, standard error.
TABLE 3. Hierarchical blockwise multiple regression model of variables predicting duration of untreated psychosis including preschool age at migration variable Unstandardized coefficients B Block 1: Academic Social Block 2: Age at onset Schizophrenia diagnosis Block 3: Preschool age at migration
SE
Standardized coefficients β
t
Sig.
95% confidence interval for B Lower
Upper
R2 change
0.381 0.381
0.188 0.147
0.095 0.120
2.021 2.594
0.044 0.010
0.010 0.092
0.751 0.670
0.057
−0.033 −0.684
0.010 0.163
−0.150 −0.189
−3.254 −4.187
0.001 0.000
−0.052 −1.005
−0.013 −0.363
0.059
−0.538
0.219
−0.110
−2.460
0.014
−0.968
−0.108
0.012
Total adjusted R2 = 0.117; total model F = 13.254, sig. = 0.000. SE, standard error.
help-seeking behaviour, such as language skills, could confound the DUP results; however, all participants in our sample did speak a Scandinavian language fluently. The rate of EMs in the current sample is at the same level as in the general population, and previous findings of equal rates of admissions24 and consultations25 because of mental illnesses in both EMs and the reference population in this catchment area indicate that findings can be generalized.
ACKNOWLEDGEMENTS
CONCLUSION
REFERENCES
Age at migration has a moderate, but statistically significant effect on DUP. The findings indicate that migrating after school start is associated with a longer DUP in immigrant population. 64
The study was supported by the Research Council of Norway, Regional Health Authority South Eastern Norway, Oslo University Hospital and the University of Oslo. We declare that none of the authors are financially involved or affiliated with any organization that may benefit from these findings. We thank all participants to the TOP study for their contribution as well as all of our colleagues who have recruited and interviewed participants to the study.
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