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Does the urban environment cause psychosis?

  • Jim Van Os (a1)
Extract

The paper by Sundquist et al is a welcome addition to a growing body of evidence linking exposures in the urban environment to the onset of schizophrenia (Sundquist et al, 2004, this issue). They also report, in agreement with the literature, that a similar association exists for depression of severity requiring hospital admission, albeit of a much lower effect size than that for schizophrenia and with the caveat that only in a small and biased proportion of cases is the person with clinical depression ever admitted to hospital. The paper represents a truly prospective analysis, and also considers confounding by other important demographic variables and changing exposure status over the period of observation.

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References
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Harrison, G., Fouskadis, D., Kasmussen, F., et al (2003) Association between psychotic disorder and urban place of birth is not mediated by obstetric complications and childhood socio-economic position: a cohort study. Psychological Medicine, 33, 723731.
Lewis, G., David, A., Andreasson, S., et al (1992) Schizophrenia and city life. Lancet, 340, 137140.
Marcelis, M., Takei, N. & van Os, J. (1999) Urbanization and risk for schizophrenia: does the effect operate before or around the time of illness onset? Psychological Medicine, 29, 11971203.
Pedersen, C. B. & Mortensen, P. B. (2001a) Evidence of a dose – response relationship between urbanicity during upbringing and schizophrenia risk. Archives of General Psychiatry, 58, 10391046.
Pedersen, C. B. & Mortensen, P. B. (2001b) Family history, p ace and season of birth as risk factors for schizophrenia in Denmark: a replication and reanalysis. British Journal of Psychiatry, 179, 4652.
Stefanis, N. C., Delespaul, P., Smirnis, N. K., et al (2004) Is the excess risk of psychosis in urban areas attributable to altered cognitive development? Social Psychiatry and Psychiatric Epidemiology, in press.
Sundquist, K., Frank, G. & Sundquist, J. (2004) Urbanisation and incidence of psychosis and depression. Follow-up study of 4.4 million women and men in Sweden. British Journal of Psychiatry, 184, 293298.
Van Os, J., Driessen, G., Gunther, N., et al (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., et al (2001) Prevalence of psychotic disorder and community level of psychotic symptoms: an urban – rural comparison. Archives of General Psychiatry, 58, 663668.
Van Os, J., Hanssen, M., Bak, M., et al (2003) Do urbanicity and familial liability coparticipate in causing psychosis? American Journal of Psychiatry, 160, 477482.
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Does the urban environment cause psychosis?

  • Jim Van Os (a1)
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eLetters

Ubanicity and Early Cannabis Use in Pyschosis

Karl Marlowe, Consultant Psychiatrist
18 May 2004

Sir,

Van Os (2004) discusses the implications from the epidemilogical research by Sundquist et al (2004) that psychosis may indeed be due to urban toxicity. The dose-response increase in urbanicity with schizophrenia does tend to an explanation of causation rather than association. The discussion of an environmental set of factors acting between birth and the onset of psychosis (child and adolescence) should have led to a discussion of the role that cannabis plays in the early onset of psychosis. This link of substance use and unbanicity was however not discussed in the editorial.

The clue to an ecological exposure lies in the association of early use of cannabis. Arseneault et al, (2002) in a prospective study found an association with the early use of cannabis by the age of 15, with an increased risk of psychosis for 1,037 children born in New Zealand. This aetiological factor interacts with the increased social fragmentation, social inequality and social isolation found with greater urbanicity. The cognitive vulnerabilities for psychosis has a strong social environmental aetiology, and linking a model of urban toxicity with increased early cannabis use needs to be made.

Reference

Arseneault, L., Cannon, M., Poulton, R., Casi, A. & Moffitt, T.E.(2002) Cannabis use in adolescence and risk for adult psychosis: longitudinal prospective study. British Medical Journal, 325, 121-1213.

Sundquist, K., Frank, G. & Sundquist, J. (2004) Urbanisation and incidence of psychosis and depression. Follow-up study of 4.4 million women and men in Sweden. British Journal of Psychiatry, 184, 293 –298.

Van Os, J (2004) Does the urban environment cause psychosis? British Journal of Psychiatry, 184, 287 –288.
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Conflict of interest: None Declared

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Immigrants, Urbanicity and Psychosis

Andrew Al-Adwani, Consultant Psychiatrist
15 April 2004

Sir: The increase in schizophrenia amongst immigrants is well documented and much debated. Dr. Van Os asks us to wake up to the link between urbanicity and psychoses. Though obviously multifactorial and complex, given that the majority of immigrants relocate to western urban environments, is there a common causal link in this process? Apart from the stress of accomodating to an alien culture, language and biological milieu, 'adapting' to an western urban lifestyle may act in synergy so as to produce the large differences in the incidence of schizophrenia in immigrants. If this is so then those who migrate from rural living to cities should be expected to have the highest incidence of schizophrenia and the inverse should hold. Whether the known epidemiology bears this out is, as far as I am aware, open to question. ... More

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