Back to top Open menu arrow
Download Reprints
Sections
METHODS RESULTS DISCUSSION Clinical points
The Journal of Clinical Psychiatry The Journal of Clinical Psychiatry

The Journal of
Clinical Psychiatry
Access icon

Original Research Focus on Psychosis March 13, 2023

Neighborhood Vulnerability and Disability in First Episode of Psychosis: A Multilevel Study

Ana Izquierdo, PhD; María Cabello, PhD; Itziar Leal, PhD; Iosune Torio, PhD; José L. M. Madrigal, PhD; Karina S. MacDowell, PhD; Roberto Rodriguez-Jimenez, PhD; David Rentero, MD; Ángela Ibáñez, PhD; Miriam Ayora, MD; Covadonga M. Díaz-Caneja, PhD; Renzo Abregú-Crespo, MSc; Blanca Mellor-Marsá, PhD; Marina Díaz-Marsá, PhD; Norberto Malpica, PhD; María-Fé Bravo-Ortiz, PhD; Enrique Baca-García, PhD; Celso Arango, PhD; Jose Luis Ayuso-Mateos, PhD; AGES-CM Group

J Clin Psychiatry 2023;84(2):22m14401

ABSTRACT

Objective: Neighborhood socioeconomic status seems to be related to functioning in patients with first episode of psychosis (FEP). The present study aimed to assess if neighborhood vulnerability and risk of social exclusion could predict functional outcomes in people with FEP after controlling for other key variables identified in previous literature.

Methods: A total of 137 patients with FEP (DSM-IV-TR criteria) and 90 controls comprised the study sample from February 2013 to May 2019. Functioning was assessed with the WHO Disability Assessment Schedule. Neighborhood vulnerability was measured using a multidimensional socioeconomic deprivation index; data for the index were collected by the Madrid City Council and based on the participant’s home address. Multilevel mixed-effects regression analyses were conducted to estimate the effects of neighborhood vulnerability on functioning.

Results: Our results show that FEP patients could be more vulnerable to the effects of neighborhood-level characteristics than healthy controls (B = 1,570.173; z = 3.91; P < .001). In addition, our findings suggest that higher neighborhood vulnerability is related to greater functional disability in people with FEP, after controlling for other relevant confounders (B = 1,230.332; z = 2.59; P = .010).

Conclusions: These results highlight the importance of incorporating contextual factors into assessment of patients with FEP, since psychosocial difficulties observed in these patients could be partially related to the quality of neighborhood social-related resources.

Continue Reading...

Did you know members enjoy unlimited free PDF downloads as part of their subscription? Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

Purchase PDF for $40

Members enjoy free PDF downloads on all articles. Join today

  1. Lund C, Brooke-Sumner C, Baingana F, et al. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry. 2018;5(4):357–369. PubMed CrossRef
  2. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2030. Published 2021. https://health.gov/healthypeople/objectives-and-data/social-determinants-health
  3. Sweeney S, Air T, Zannettino L, et al. Psychosis, socioeconomic disadvantage, and health service use in South Australia: findings from the Second Australian National Survey of Psychosis. Front Public Health. 2015;3:259. PubMed CrossRef
  4. Reichert A, Jacobs R. Socioeconomic inequalities in duration of untreated psychosis: evidence from administrative data in England. Psychol Med. 2018;48(5):822–833. PubMed CrossRef
  5. Oluwoye O, Amiri S, Kordas G, et al. Geographic disparities in access to specialty care programs for early psychosis in Washington State. Adm Policy Ment Health. 2022;49(1):5–12. PubMed CrossRef
  6. Drukker M, van Os J. Mediators of neighbourhood socioeconomic deprivation and quality of life. Soc Psychiatry Psychiatr Epidemiol. 2003;38(12):698–706. PubMed CrossRef
  7. Hui CLM, Ko WT, Chang WC, et al. Clinical and functional correlates of financially deprived women with first-episode psychosis. Early Interv Psychiatry. 2019;13(3):639–645. PubMed CrossRef
  8. Samele C, van Os J, McKenzie K, et al; UK700 Group. Does socioeconomic status predict course and outcome in patients with psychosis? Soc Psychiatry Psychiatr Epidemiol. 2001;36(12):573–581. PubMed CrossRef
  9. Bentall RP, de Sousa P, Varese F, et al. From adversity to psychosis: pathways and mechanisms from specific adversities to specific symptoms. Soc Psychiatry Psychiatr Epidemiol. 2014;49(7):1011–1022. PubMed CrossRef
  10. Kirkbride JB, Jones PB, Ullrich S, et al. Social deprivation, inequality, and the neighborhood-level incidence of psychotic syndromes in East London. Schizophr Bull. 2014;40(1):169–180. PubMed CrossRef
  11. Wickham S, Taylor P, Shevlin M, et al. The impact of social deprivation on paranoia, hallucinations, mania and depression: the role of discrimination social support, stress and trust. PLoS One. 2014;9(8):e105140. PubMed CrossRef
  12. Heinz A, Deserno L, Reininghaus U. Urbanicity, social adversity and psychosis. World Psychiatry. 2013;12(3):187–197. PubMed CrossRef
  13. Allardyce J, Gilmour H, Atkinson J, et al. Social fragmentation, deprivation and urbanicity: relation to first-admission rates for psychoses. Br J Psychiatry. 2005;187(5):401–406. PubMed CrossRef
  14. Jongsma HE, Gayer-Anderson C, Lasalvia A, et al; European Network of National Schizophrenia Networks Studying Gene-Environment Interactions Work Package 2 (EU-GEI WP2) Group. Treated incidence of psychotic disorders in the multinational EU-GEI Study. JAMA Psychiatry. 2018;75(1):36–46. PubMed CrossRef
  15. Kirkbride JB, Stochl J, Zimbrón J, et al. Social and spatial heterogeneity in psychosis proneness in a multilevel case-prodrome-control study. Acta Psychiatr Scand. 2015;132(4):283–292. PubMed CrossRef
  16. O’Donoghue B, Roche E, Lane A. Neighbourhood level social deprivation and the risk of psychotic disorders: a systematic review. Soc Psychiatry Psychiatr Epidemiol. 2016;51(7):941–950. PubMed CrossRef
  17. Eaton S, Harrap B, Downey L, et al. Incidence of treated first episode psychosis from an Australian early intervention service and its association with neighbourhood characteristics. Schizophr Res. 2019;209:206–211. PubMed CrossRef
  18. Burns JK, Esterhuizen T. Poverty, inequality and the treated incidence of first-episode psychosis: an ecological study from South Africa. Soc Psychiatry Psychiatr Epidemiol. 2008;43(4):331–335. PubMed CrossRef
  19. Hastings PD, Serbin LA, Bukowski W, et al. Predicting psychosis-spectrum diagnoses in adulthood from social behaviors and neighborhood contexts in childhood. Dev Psychopathol. 2020;32(2):465–479. PubMed CrossRef
  20. March D, Hatch SL, Morgan C, et al. Psychosis and place. Epidemiol Rev. 2008;30(1):84–100. PubMed CrossRef
  21. Bhavsar V, Boydell J, Murray R, et al. Identifying aspects of neighbourhood deprivation associated with increased incidence of schizophrenia. Schizophr Res. 2014;156(1):115–121. PubMed CrossRef
  22. Ribeiro AI, Fraga S, Kelly-Irving M, et al. Neighbourhood socioeconomic deprivation and allostatic load: a multi-cohort study. Sci Rep. 2019;9(1):8790. PubMed CrossRef
  23. Bhavsar V. Is neighbourhood effects research in psychosis fit for purpose? commentary on Eaton et al. Schizophr Res. 2020;215:6–7. PubMed CrossRef
  24. Silva M, Loureiro A, Cardoso G. Social determinants of mental health: a review of the evidence. Eur J Psychiatry. 2016;30:259–292.
  25. Vargas T, Conley RE, Mittal VA. Chronic stress, structural exposures and neurobiological mechanisms: a stimulation, discrepancy and deprivation model of psychosis. Int Rev Neurobiol. 2020;152:41–69. PubMed CrossRef
  26. Wilson C, Smith ME, Thompson E, et al. Context matters: the impact of neighborhood crime and paranoid symptoms on psychosis risk assessment. Schizophr Res. 2016;171(1–3):56–61. PubMed CrossRef
  27. Drukker M, Krabbendam L, Driessen G, et al. Social disadvantage and schizophrenia: a combined neighbourhood and individual-level analysis. Soc Psychiatry Psychiatr Epidemiol. 2006;41(8):595–604. PubMed CrossRef
  28. Steele LS, Glazier RH, Lin E. Inequity in mental health care under Canadian universal health coverage. Psychiatr Serv. 2006;57(3):317–324. PubMed CrossRef
  29. Kahn RS, Wise PH, Kennedy BP, et al. State income inequality, household income, and maternal mental and physical health: cross sectional national survey. BMJ. 2000;321(7272):1311–1315. PubMed CrossRef
  30. Krabbendam L, van Os J. Schizophrenia and urbanicity: a major environmental influence–conditional on genetic risk. Schizophr Bull. 2005;31(4):795–799. PubMed CrossRef
  31. Ku BS, Pauselli L, Manseau M, et al. Neighborhood-level predictors of age at onset and duration of untreated psychosis in first-episode psychotic disorders. Schizophr Res. 2020;218:247–254. PubMed CrossRef
  32. Burns JK, Tomita A, Kapadia AS. Income inequality and schizophrenia: increased schizophrenia incidence in countries with high levels of income inequality. Int J Soc Psychiatry. 2014;60(2):185–196. PubMed CrossRef
  33. Fett AJ, Lemmers-Jansen ILJ, Krabbendam L. Psychosis and urbanicity: a review of the recent literature from epidemiology to neurourbanism. Curr Opin Psychiatry. 2019;32(3):232–241. PubMed CrossRef
  34. van Os J, Kenis G, Rutten BPF. The environment and schizophrenia. Nature. 2010;468(7321):203–212. PubMed CrossRef
  35. Compton MT, Shim RS. The social determinants of mental health. Focus. 2015;13(4):419–425. CrossRef
  36. Hernando-Merino E, Baca-Garcia E, Barrigón ML. Comparación de la discapacidad entre trastornos mentales graves y comunes usando la escala WHODAS 2.0. Rev Psiquiatr Salud Ment. 2022;15(3):205–210. CrossRef
  37. Schneidert M, Hurst R, Miller J, et al. The role of environment in the International Classification of Functioning, Disability and Health (ICF). Disabil Rehabil. 2003;25(11-12):588–595. PubMed CrossRef
  38. WHO. How to Use the ICF: A Practical Manual for Using the International Classification of Functioning, Disability and Health (ICF). World Health Organization; 2013.
  39. Ku BS, Compton MT, Walker EF, et al. Social fragmentation and schizophrenia: a systematic review. J Clin Psychiatry. 2021;83(1):21r13941. PubMed CrossRef
  40. Baker SJ, Jackson M, Jongsma H, et al. The ethnic density effect in psychosis: a systematic review and multilevel meta-analysis. Br J Psychiatry. 2021;219(6):632–643. PubMed CrossRef
  41. Vázquez-Barquero JL, Cuesta MJ, Herrera Castanedo S, et al. Cantabria First-Episode Schizophrenia Study: three-year follow-up. Br J Psychiatry. 1999;174(2):141–149. PubMed CrossRef
  42. Abdin E, Chong SA, Vaingankar JA, et al. Trajectories of positive, negative and general psychopathology symptoms in first episode psychosis and their relationship with functioning over a 2-year follow-up period. PLoS One. 2017;12(11):e0187141. PubMed CrossRef
  43. Hall MH, Holton KM, Öngür D, et al. Longitudinal trajectory of early functional recovery in patients with first episode psychosis. Schizophr Res. 2019;209:234–244. PubMed CrossRef
  44. Austin SF, Mors O, Secher RG, et al. Predictors of recovery in first episode psychosis: the OPUS cohort at 10 year follow-up. Schizophr Res. 2013;150(1):163–168. PubMed CrossRef
  45. Bratlien U, Øie M, Lien L, et al. Social dysfunction in first-episode psychosis and relations to neurocognition, duration of untreated psychosis and clinical symptoms. Psychiatry Res. 2013;207(1–2):33–39. PubMed CrossRef
  46. Mellor-Marsá B, Caballero FF, Cabello M, et al. Disability multilevel modelling in first episodes of psychosis at 3-year follow-up. Schizophr Res. 2017;185:101–106. PubMed CrossRef
  47. Robertson BR, Prestia D, Twamley EW, et al. Social competence versus negative symptoms as predictors of real world social functioning in schizophrenia. Schizophr Res. 2014;160(1–3):136–141. PubMed CrossRef
  48. White C, Stirling J, Hopkins R, et al. Predictors of 10-year outcome of first-episode psychosis. Psychol Med. 2009;39(9):1447–1456. PubMed CrossRef
  49. Fett AKJ, Viechtbauer W, Dominguez MD, et al. The relationship between neurocognition and social cognition with functional outcomes in schizophrenia: a meta-analysis. Neurosci Biobehav Rev. 2011;35(3):573–588. PubMed CrossRef
  50. Green MF, Bearden CE, Cannon TD, et al. Social cognition in schizophrenia, part 1: performance across phase of illness. Schizophr Bull. 2012;38(4):854–864. PubMed CrossRef
  51. Horan WP, Green MF, DeGroot M, et al. Social cognition in schizophrenia, part 2: 12-month stability and prediction of functional outcome in first-episode patients. Schizophr Bull. 2012;38(4):865–872. PubMed CrossRef
  52. Bergé D, Mané A, Salgado P, et al. Predictors of relapse and functioning in first-episode psychosis: a two-year follow-up study. Psychiatr Serv. 2016;67(2):227–233. PubMed CrossRef
  53. Chang WC, Chu AOK, Kwong VWY, et al. Patterns and predictors of trajectories for social and occupational functioning in patients presenting with first-episode non-affective psychosis: a three-year follow-up study. Schizophr Res. 2018;197:131–137. PubMed CrossRef
  54. Gardner A, Cotton SM, Allott K, et al. Social inclusion and its interrelationships with social cognition and social functioning in first-episode psychosis. Early Interv Psychiatry. 2019;13(3):477–487. PubMed CrossRef
  55. Friis S, Melle I, Johannessen JO, et al. Early predictors of ten-year course in first-episode psychosis. Psychiatr Serv. 2016;67(4):438–443. PubMed CrossRef
  56. Izquierdo A, Cabello M, Leal I, et al; AGES-CM group. How does neighbourhood socio-economic status affect the interrelationships between functioning dimensions in first episode of psychosis? a network analysis approach. Health Place. 2021;69:102555. PubMed CrossRef
  57. Aliño JJLI, Miyar MV. DSM-IV-TR: Manual Diagnóstico y Estadístico de Los Trastornos Mentales. American Psychiatric Publishing; 2008.
  58. Hollingshead A. Two Factor Index of Social Position. Yale University Press; 1957.
  59. World Health Organization. Medición de la salad y la discapacidad: manual para el cuestionario de evaluación de la discapacidad de la OMS: WHODAS 2.0. Servicio Nacional de Rehabilitación. 2015. https://apps.who.int/iris/handle/10665/170500
  60. Üstün TB, ed. Measuring Health and Disability: Manual for WHO Disability Assessment Schedule WHODAS 2.0. World Health Organization; 2010.
  61. Barajas A, Ochoa S, Baños I, et al; GENIPE group. Spanish validation of the Premorbid Adjustment Scale (PAS-S). Compr Psychiatry. 2013;54(2):187–194. PubMed CrossRef
  62. Cannon-Spoor HE, Potkin SG, Wyatt RJ. Measurement of premorbid adjustment in chronic schizophrenia. Schizophr Bull. 1982;8(3):470–484. PubMed CrossRef
  63. Goepel KD. Implementing the analytic hierarchy process as a standard method for multi-criteria decision making in corporate enterprises – a new AHP Excel template with multiple inputs. Proceedings of the International Symposium on the Analytic Hierarchy Process 2013. CrossRef >
  64. Metodología para la elaboración del índice de vulnerabilidad territorial de barrios y distritos de Madrid y ranking de vulnerabilidad. Ayunt Madr Spain. https://www.madrid.es/UnidadWeb/Contenidos/Publicaciones/TemaServiciosSociales/IndiceVulnerabil/indicevulnerabilidad.pdf. Published online 2018.
  65. First MB. Structured Clinical Interview for DSM-IV Axis I Disorders. Biom Res Dep. CiNii website. https://ci.nii.ac.jp/naid/10027499505/en/. Published online 1997.
  66. Ulloa RE, Ortiz S, Higuera F, et al. Interrater reliability of the Spanish version of Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime version (K-SADS-PL). Actas Esp Psiquiatr. 2006;34(1):36–40. PubMed
  67. Kay SR, Fiszbein A, Opler LA. The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13(2):261–276. PubMed CrossRef
  68. Peralta Martín V, Cuesta Zorita MJ. Validation of Positive and Negative Symptom Scale (PANSS) in a sample of Spanish schizophrenic patients. Actas Luso Esp Neurol Psiquiatr Cienc Afines. 1994;22(4):171–177. PubMed
  69. Wallwork RS, Fortgang R, Hashimoto R, et al. Searching for a consensus five-factor model of the Positive and Negative Syndrome Scale for schizophrenia. Schizophr Res. 2012;137(1-3):246–250. PubMed CrossRef
  70. Rodriguez-Jimenez R, Bagney A, Mezquita L, et al; PARG. Cognition and the five-factor model of the Positive and Negative Syndrome Scale in schizophrenia. Schizophr Res. 2013;143(1):77–83. PubMed CrossRef
  71. Pardo A, Ruiz MA, San Martín R. How to fit and interpret multilevel models using SPSS. Psicothema. 2007;19(2):308–321. PubMed
  72. Stata Multilevel Mixed-Effects Reference Manual. StataCorp LP; 2013.
  73. IBM SPSS Statistics for Windows. IBM Corp; 2017.
  74. Stata Statistical Software. Version 15. StataCorp; 2017.
  75. Nuechterlein KH, Dawson ME. A heuristic vulnerability/stress model of schizophrenic episodes. Schizophr Bull. 1984;10(2):300–312. PubMed CrossRef
  76. Cheng SC, Walsh E, Schepp KG. Vulnerability, stress, and support in the disease trajectory from prodrome to diagnosed schizophrenia: diathesis-stress-support model. Arch Psychiatr Nurs. 2016;30(6):810–817. PubMed CrossRef
  77. Gispen-de Wied CC, Jansen LMC. The stress-vulnerability hypothesis in psychotic disorders: focus on the stress response systems. Curr Psychiatry Rep. 2002;4(3):166–170. PubMed CrossRef
  78. Chen R, Liou TH, Chang KH, et al. Assessment of functioning and disability in patients with schizophrenia using the WHO Disability Assessment Schedule 2.0 in a large-scale database. Eur Arch Psychiatry Clin Neurosci. 2018;268(1):65–75. PubMed CrossRef
  79. Zipursky RB, Reilly TJ, Murray RM. The myth of schizophrenia as a progressive brain disease. Schizophr Bull. 2013;39(6):1363–1372. PubMed CrossRef
  80. Taylor RL, Cooper SR, Jackson JJ, et al. Assessment of neighborhood poverty, cognitive function, and prefrontal and hippocampal volumes in children. JAMA Netw Open. 2020;3(11):e2023774. PubMed CrossRef
  81. Ku BS, Aberizk K, Addington J, et al. The association between neighborhood poverty and hippocampal volume among individuals at clinical high-risk for psychosis: the moderating role of social engagement. Schizophr Bull. 2022;48(5):1032–1042. PubMed CrossRef
  82. Retos de la movilidad en la periferia. Ayuntamiento de Madrid. https://www.madrid.es/portales/munimadrid/es/Inicio/Medio-ambiente/CIVITAS-ECCENTRIC/Sobre-Eccentric/Innovacion/Retos-de-la-movilidad-en-la-periferia/?vgnextfmt=default&vgnextoid=4f7d86428a776610VgnVCM2000001f4a900aRCRD&vgnextchannel=fe887c2edb676610VgnVCM2000001f4a900aRCRD. Published 2021. Accessed September 20, 2021.
  83. Salazar de Pablo G, De Micheli A, Nieman DH, et al. Universal and selective interventions to promote good mental health in young people: systematic review and meta-analysis. Eur Neuropsychopharmacol. 2020;41:28–39. PubMed CrossRef
  84. Bauer GF, Huber CA, Jenny GJ, et al. Socioeconomic status, working conditions and self-rated health in Switzerland: explaining the gradient in men and women. Int J Public Health. 2009;54(1):23–30. PubMed CrossRef
  85. Warren JR, Hoonakker P, Carayon P, et al. Job characteristics as mediators in SES-health relationships. Soc Sci Med. 2004;59(7):1367–1378. PubMed CrossRef
  86. Chudleigh C, Naismith SL, Blaszczynski A, et al. How does social functioning in the early stages of psychosis relate to depression and social anxiety? Early Interv Psychiatry. 2011;5(3):224–232. PubMed CrossRef
  87. Topor A, Andersson G, Denhov A, et al. Psychosis and poverty: coping with poverty and severe mental illness in everyday life. Psychosis. 2014;6(2):117–127. CrossRef
  88. Vargas T, Rakhshan Rouhakhtar PJ, Schiffman J, et al. Neighborhood crime, socioeconomic status, and suspiciousness in adolescents and young adults at Clinical High Risk (CHR) for psychosis. Schizophr Res. 2020;215:74–80. PubMed CrossRef
  89. Shim R, Koplan C, Langheim FJP, et al. The social determinants of mental health: an overview and call to action. Psychiatr Ann. 2014;44(1):22–26. CrossRef
  90. Fusar-Poli P, Salazar de Pablo G, De Micheli A, et al. What is good mental health? a scoping review. Eur Neuropsychopharmacol. 2020;31:33–46. PubMed CrossRef
Purchase PDF for $40

Members enjoy free PDF downloads on all articles. Join today

Save Save

Share Share

Cite Cite

Vol 85 • 2024 • Number 3

Read the Current Issue

Editorial

Focus on Women’s Mental Health: Twenty Years and Counting

Original Research

Esmethadone in Patients With Major Depressive Disorder and Inadequate Response to Standard Antidepressants

Commentary

Can Our Collective Experiences As Clinicians Improve Mental Health Care?

Original Research

Prescription Opioid Use Disorder in US Adults Reporting Prescription Opioid Use

Original Research

Symptomatic Disorders Comorbid with Borderline Personality Disorder Over Time

Original Research

Aripiprazole Lauroxil Initiation Regimens
View current Issue

Celebrating
85 Years

Read the Journal of Clinical Psychiatry

Subscribe to read
more articles

Subscribe