Skip to main content

Neighbourhood-level effects on psychoses: re-examining the role of context


The incidence of schizophrenia varies by individual-level characteristics and neighbourhood-level attributes. Few specific socio-environmental risk factors (SERFs) have been identified at the neighbourhood level. Cross-level interactions are poorly understood. We investigated these issues using data from the Aetiology and Ethnicity in Schizophrenia and Other Psychoses (AESOP) study.


All incidence cases of ICD-10 schizophrenia (F20) and other non-affective psychoses (F21–29), aged 16–64 years, across 33 wards in Southeast London were identified over a 2-year period (1997–1999). Census data provided the denominator for each ward. Multilevel Poisson regression simultaneously modelled individual- and neighbourhood-level SERFs, including socio-economic deprivation, voter turnout (proxy for social capital), ethnic fragmentation (segregation) and ethnic density.


A total of 218 subjects were identified during 565 576 person-years at risk. Twenty-three per cent of variance in incidence of schizophrenia across wards could be attributed to neighbourhood-level risk factors [95% confidence interval (CI) 9·9–42·2]. Thus, 1% increases in voter turnout [incidence rate ratio (IRR) 0·95, 95% CI 0·92–0·99] and ethnic segregation (IRR 0·95, 95% CI 0·92–0·99) were both independently associated with a reduced incidence of 5%, independent of age, sex, ethnicity, deprivation and population density. This was similar for other non-affective psychoses. There was some evidence that ethnic minority individuals were at greater risk of schizophrenia in areas with smaller proportions of minority groups (p=0·07).


SERFs at individual and neighbourhood levels were implicated in the aetiology of psychosis, but we were unable to determine whether these associations were causal. Individual risk may be mediated by social capital, which could operate as a protective factor, perhaps moderating social stress in the onset of psychoses.

Corresponding author
*Address for correspondence: James B. Kirkbride, Ph.D., Department of Psychiatry, University of Cambridge, Box 189, Cambridge CB2 2QQ, UK. (Email:
Hide All
Allardyce J., Gilmour H., Atkinson J., Rapson T., Bishop J. & McCreadie R. G. (2005). Social fragmentation, deprivation and urbanicity: relation to first-admission rates for psychoses. British Journal of Psychiatry 187, 401406.
Boydell J., van Os J., McKenzie K., Allardyce J., Goel R., McCreadie R. G. & Murray R. M. (2001). Incidence of schizophrenia in ethnic minorities in London: ecological study into interactions with environment. British Medical Journal 323, 13361338.
Cochrane R. & Bal S. S. (1988). Ethnic density is unrelated to incidence of schizophrenia. British Journal of Psychiatry 153, 363366.
Cooper B. (2005). Immigration and schizophrenia: the social causation hypothesis revisited. British Journal of Psychiatry 186, 361363.
Cooper J. E., Goodhead D., Craig T., Harris M., Howat J. & Korer J. (1987). The incidence of schizophrenia in Nottingham. British Journal of Psychiatry 151, 619626.
Croudace T. J., Kayne R., Jones P. B. & Harrison G. L. (2000). Non-linear relationship between an index of social deprivation, psychiatric admission prevalence and the incidence of psychosis. Psychological Medicine 30, 177185.
Crow T. J. (2000). Schizophrenia as the price that homo sapiens pays for language: a resolution of the central paradox in the origin of the species. Brain Research Reviews 31, 118129.
De Silva M. J., McKenzie K., Harpham T. & Huttly S. R. (2005). Social capital and mental illness: a systematic review. Journal of Epidemiology and Community Health 59, 619627.
Diez-Roux A. V., Nieto F. J., Muntaner C., Tyroler H. A., Comstock G. W., Shahar E., Cooper L. S., Watson R. L. & Szklo M. (1997). Neighborhood environments and coronary heart disease: a multilevel analysis. American Journal of Epidemiology 146, 4863.
Drukker M., Krabbendam L., Driessen G. & van Os J. (2006). Social disadvantage and schizophrenia: a combined neighbourhood- and individual-level analysis. Social Psychiatry and Psychiatric Epidemiology 41, 595604.
Faris R. E. L. & Dunham H. W. (1939). Mental Disorders in Urban Areas. University of Chicago Press: Chicago.
Fearon P., Kirkbride J. B., Morgan C., Dazzan P., Morgan K., Lloyd T., Hutchinson G., Tarrant J., Lun Alan Fung W., Holloway J., Mallett R., Harrison G., Leff J., Jones P. B. & Murray R. M. (2006). Incidence of schizophrenia and other psychoses in ethnic minority groups: results from the MRC AESOP study. Psychological Medicine 36, 15411550.
Garety P. A., Kuipers E., Fowler D., Freeman D. & Bebbington P. E. (2001). A cognitive model of the positive symptoms of psychosis. Psychological Medicine 31, 189195.
Hollingshead A. B. & Redlich F. C. (1958). Social Class and Mental Illness. Wiley: New York.
Howes O. D., McDonald C., Cannon M., Arseneault L., Boydell J. & Murray R. M. (2004). Pathways to schizophrenia: the impact of environmental factors. International Journal of Neuropsychopharmacology 7 (Suppl. 1), S7S13.
Jablensky A., Sartorius N., Ernberg G., Anker M., Korten A., Cooper J. E., Day R. & Bertelsen A. (1992). Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychological Medicine. Monograph Supplement 20, 197.
Jones P. B., Bebbington P., Foerster A., Lewis S. W., Murray R. M., Russell A., Sham P. C., Toone B. K. & Wilkins S. (1993). Premorbid social underachievement in schizophrenia. Results from the Camberwell Collaborative Psychosis Study. British Journal of Psychiatry 162, 6571.
Kirkbride J. B., Fearon P., Morgan C., Dazzan P., Morgan K., Murray R. M. & Jones P. B. (in press). Neighbourhood variation in the incidence of psychotic disorders in Southeast London. Social Psychiatry and Psychiatric Epidemiology.
Kirkbride J. B., Fearon P., Morgan C., Dazzan P., Morgan K., Tarrant J., Lloyd T., Holloway J., Hutchinson G., Leff J. P., Mallett R. M., Harrison G. L., Murray R. M. & Jones P. B. (2006). Heterogeneity in incidence rates of schizophrenia and other psychotic syndromes: findings from the 3-center ÆSOP Study. Archives of General Psychiatry 63, 250258.
Krabbendam L. & van Os J. (2005). Schizophrenia and urbanicity: a major environmental influence – conditional on genetic risk. Schizophrenia Bulletin 31, 795799.
Lewis G., David A., Andreasson S. & Allebeck P. (1992). Schizophrenia and city life. Lancet 340, 137140.
Mallett M. R. (1997). MRC Sociodemographic Schedule. Institute of Psychiatry: London.
McCulloch A. (2001). Social environments and health: cross-sectional national survey. British Medical Journal 323, 208209.
McKenzie K., Whitley R. & Weich S. (2002). Social capital and mental health. British Journal of Psychiatry 181, 280283.
Mortensen P. B., Pedersen C. B., Westergaard T., Wohlfahrt J., Ewald H., Mors O., Andersen P. K. & Melbye M. (1999). Effects of family history and place and season of birth on the risk of schizophrenia. New England Journal of Medicine 340, 603608.
Myin-Germeys I., van Os J., Schwartz J. E., Stone A. A. & Delespaul P. A. (2001). Emotional reactivity to daily life stress in psychosis. Archives of General Psychiatry 58, 11371144.
ODPM (2004). The English Indices of Deprivation 2004. Office of the Deputy Prime Minister: Wetherby ( Accessed 19 October 2006.
Peach C. (1981). Conflicting interpretations of segregation. In Social Interaction and Ethnic Segregation, vol. 12 (ed. Jackson P. and Smith S.), pp. 1933. Institute of British Geographers (IBG) Special Publication. Academic Press: London.
Peach C. (1996). Does Britain have ghettos? Transactions of the Institute of British Geographers 21, 216235.
Pedersen C. B. & Mortensen P. B. (2001). Evidence of a dose–response relationship between urbanicity during upbringing and schizophrenia risk. Archives of General Psychiatry 58, 10391046.
Pilgrim D. & Roger A. (2005). Social psychiatry and sociology. Journal of Mental Health 14, 317320.
Putnam R. (1993). Making Democracy Work: Civic Traditions in Modern Italy. Princeton University Press: Princeton, NJ.
Rawlings C. & Thrasher M. (2002). The Local Elections Handbook. Local Government Chronicle Elections Centre: Plymouth.
Sampson R. J., Raudenbush S. W. & Earls F. (1997). Neighborhoods and violent crime: a multilevel study of collective efficacy. Science 277, 918924.
Silver E., Mulvey E. P. & Swanson J. W. (2002). Neighborhood structural characteristics and mental disorder: Faris and Dunham revisited. Social Science and Medicine 55, 14571470.
Smith G. D. & Dorling D. (1996). ‘I'm all right, John’: voting patterns and mortality in England and Wales, 1981–92. British Medical Journal 313, 15731577.
StataCorp (2005). STATA Statistical Software. Stata Corporation: College Station, TX.
Takei N., O'Callaghan E. & Sham P. (1992). Winter birth excess in schizophrenia: its relationship to place of birth. Schizophrenia Research 6, 102108.
van Os J. (2004). Does the urban environment cause psychosis? British Journal of Psychiatry 184, 287288.
van Os J., Driessen G., Gunther N. & Delespaul P. (2000). Neighbourhood variation in incidence of schizophrenia. Evidence for person–environment interaction. British Journal of Psychiatry 176, 243248.
van Os J., Hanssen M., Bijl R. V. & Vollebergh W. (2001). Prevalence of psychotic disorder and community level of psychotic symptoms: an urban–rural comparison. Archives of General Psychiatry 58, 663668.
Veling W. A., Selten J. P., Van Hoeken D., Hoek H. W. & Mackenbach J. P. (2006). Ethnic density and incidence of schizophrenia in ethnic minorities in the Netherlands. Schizophrenia Research 81, 174174.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
  • URL: /core/journals/psychological-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Full text views

Total number of HTML views: 15
Total number of PDF views: 96 *
Loading metrics...

Abstract views

Total abstract views: 325 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 21st November 2017. This data will be updated every 24 hours.