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QUESTION: What is the 3 year pattern of recovery and diagnostic stability among African-Caribbean patients with a first episode psychosis?
Inception cohort followed up for 3 years.
Population based study in Nottingham, UK.
166 patients aged 16–64 years (mean age 31 y, 59% men, 25% African Caribbean family origin) with a first episode psychosis identified between June 1992 and May 1994.
Assessment of prognostic factors
At baseline, a diagnosis was made using ICD-10 and DSM-III-R criteria and sociodemographic data were collected. African-Caribbean status was defined by patients' and parents' place of birth.
Main outcome measures
Pattern of course of psychosis (including symptoms, social disability, course, type, and resource use) and diagnostic stability.
Some information on course and outcome of the psychosis was available for 97% of patients. None of the 3 year outcome variables (scores on the Schedules for Clinical Assessment in Neuropsychiatry, Scale for the Assessment of Negative Symptoms, Psychiatric Disability Assessment Schedule, and the Global Assessment of Function scale) showed statistically significant differences in the number or severity of positive symptoms or social disability between African-Caribbean patients (n=33) and those of other ethnic origins (n=133). The number of psychiatric admissions (mean difference –0.4, 95% CI –1.0 to 0.2) and duration of first admissions were also comparable between the 2 groups. Diagnostic profiles were similar, with no evidence of greater diagnostic instability in the African-Caribbean group (75% of ICD-10 schizophrenia cases were stable in the African-Caribbean group, which was comparable with that in the non-Caribbean group). After adjustment for sex, social class, age, diagnosis, and duration of untreated illness, pattern of illness course was similar between African-Caribbean patients and non-Caribbean patients (adjusted odds ratio on the Operational Criteria Checklist course type: partial recovery or continuous chronic v single episode or good recovery 0.6, 95% CI 0.2 to 1.7).
Pattern of course of psychosis and diagnostic stability did not differ by ethnic family background.
Of interest to the clinician is an answer to the following question: do ethnic minority patients such as people of Caribbean origin have a different course of illness than their white British peers? This question clearly has face validity because ethnic minority status is associated with differences in pathway to care, service uptake, risk of misdiagnosis, treatment adherence, and cultural influences on perceptions of illness aetiology and treatment. The combined effect of these differences may well influence course and outcome. How helpful are the studies by Goater et al and Harrison et al?
Authors of both studies refer to previous publications for a clear description of the ethnic composition of their samples. Goater et al combine a group of patients of Caribbean and African origin on the basis of their appearance into a “black” group, whereas a group of Indian, Pakistani, and other Asians are grouped together on the basis on their place of origin into an “Asian” group. Finally, a group of patients of Greek, Turkish, Irish, British, and other European origin is again grouped on the basis of appearance into a “white” group. Of the white group, actually fewer than half were of British white origin. The question arises of how meaningful is the comparison between the black and white groups in this study. Both groups are defined on the basis of appearance, making the comparison more a racial than an ethnic one. The fact that more than half of the white group were of non-British origin means that differences due to ethnic minority status, if they existed, would be difficult to detect in this small sample.
Harrison et al were able to define a group of patients of Caribbean origin. Illness course in this group, however, was compared with all other ethnic groups lumped together. Although their previous publications suggest that the number of patients of African and Asian origin was small, no data are given on the origin of the white patients. Their groups, however, are clearly more homogeneous ethnically than the ones in the study of Goater et al and as such constitute a more relevant contrast clinically.
Neither study reports how large a difference in course they expected to find, nor how large their study samples needed to be to be able to detect such a difference. If we assume a clinically relevant effect size of 2—that is, the odds of a single episode/good recovery is 2 times higher in African-Caribbean patients—then the study by Harrison et al would have had approximately 40% chance of detecting it. On the other hand, they would have had 85% chance of detecting an effect of 3.
So what can clinicians conclude from these 2 studies? If we wish to know whether ethnic minority status, for example African-Caribbean ethnic group, is associated with a more benign illness course which, though not hugely different, may still constitute a large enough difference to make it relevant clinically, we must (1) make sure that the ethnic composition of the comparison groups matches the hypothesis, and (2) make sure we have a large enough sample to be able to detect it.
Source of funding: National Health Service Executive (Trent Research & Development), UK.
For correspondence: Dr G Harrison, Division of Psychiatry, University of Bristol, 41 St Michael's Hill, Bristol BS2 8DZ, UK. Fax +44 (0)1179 279709.
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