Jordan E DeVylder1, Ian Kelleher2, Monique Lalane1, Hans Oh3, Bruce G Link4,5, Ai Koyanagi6,7. 1. Graduate School of Social Service, Fordham University, New York, New York. 2. Department of Psychiatry, Royal College of Surgeons, Dublin, Ireland. 3. School of Social Work, University of Southern California, Los Angeles. 4. Department of Sociology, University of California, Riverside. 5. Department of Public Policy, University of California, Riverside. 6. Research and Development Unit, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain. 7. Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain.
Abstract
Importance: Urban residence is one of the most well-established risk factors for psychotic disorder, but most evidence comes from a small group of high-income countries. Objective: To determine whether urban living is associated with greater odds for psychosis in low- and middle-income countries (LMICs). Design, Setting, and Participants: This international population-based study used cross-sectional survey data collected as part of the World Health Organization (WHO) World Health Survey from May 2, 2002, through December 31, 2004. Participants included nationally representative general population probability samples of adults (≥18 years) residing in 42 LMICs (N = 215 682). Data were analyzed from November 20 through December 5, 2017. Exposures: Urban vs nonurban residence, determined by the WHO based on national data. Main Outcomes and Measures: Psychotic experiences, assessed using the WHO Composite International Diagnostic Interview psychosis screen, and self-reported lifetime history of a diagnosis of a psychotic disorder. Results: Among the 215 682 participants (50.8% women and 49.2% men; mean [SD] age, 37.9 [15.7] years), urban residence was not associated with psychotic experiences (odds ratio [OR], 0.99; 95% CI, 0.89-1.11) or psychotic disorder (OR, 0.89; 95% CI, 0.76-1.06). Results of all pooled analyses and meta-analyses of within-country effects approached a null effect, with an overall OR of 0.97 (95% CI, 0.87-1.07), OR for low-income countries of 0.98 (95% CI, 0.82-1.15), and OR for middle-income countries of 0.96 (95% CI, 0.84-1.09) for psychotic experiences and an overall OR of 0.92 (95% CI, 0.73-1.16), OR for low-income countries of 0.92 (95% CI, 0.66-1.27), and OR for middle-income countries of 0.92 (95% CI, 0.67-1.27) for psychotic disorder. Conclusions and Relevance: Our results provide evidence that urbanicity, a well-established risk factor for psychosis, may not be associated with elevated odds for psychosis in developing countries. This finding may provide better understanding of the mechanisms by which urban living may contribute to psychosis risk in high-income countries, because urban-rural patterns of cannabis use, racial discrimination, and socioeconomic disparities may vary between developing and developed nations.
Importance: Urban residence is one of the most well-established risk factors for psychotic disorder, but most evidence comes from a small group of high-income countries. Objective: To determine whether urban living is associated with greater odds for psychosis in low- and middle-income countries (LMICs). Design, Setting, and Participants: This international population-based study used cross-sectional survey data collected as part of the World Health Organization (WHO) World Health Survey from May 2, 2002, through December 31, 2004. Participants included nationally representative general population probability samples of adults (≥18 years) residing in 42 LMICs (N = 215 682). Data were analyzed from November 20 through December 5, 2017. Exposures: Urban vs nonurban residence, determined by the WHO based on national data. Main Outcomes and Measures: Psychotic experiences, assessed using the WHO Composite International Diagnostic Interview psychosis screen, and self-reported lifetime history of a diagnosis of a psychotic disorder. Results: Among the 215 682 participants (50.8% women and 49.2% men; mean [SD] age, 37.9 [15.7] years), urban residence was not associated with psychotic experiences (odds ratio [OR], 0.99; 95% CI, 0.89-1.11) or psychotic disorder (OR, 0.89; 95% CI, 0.76-1.06). Results of all pooled analyses and meta-analyses of within-country effects approached a null effect, with an overall OR of 0.97 (95% CI, 0.87-1.07), OR for low-income countries of 0.98 (95% CI, 0.82-1.15), and OR for middle-income countries of 0.96 (95% CI, 0.84-1.09) for psychotic experiences and an overall OR of 0.92 (95% CI, 0.73-1.16), OR for low-income countries of 0.92 (95% CI, 0.66-1.27), and OR for middle-income countries of 0.92 (95% CI, 0.67-1.27) for psychotic disorder. Conclusions and Relevance: Our results provide evidence that urbanicity, a well-established risk factor for psychosis, may not be associated with elevated odds for psychosis in developing countries. This finding may provide better understanding of the mechanisms by which urban living may contribute to psychosis risk in high-income countries, because urban-rural patterns of cannabis use, racial discrimination, and socioeconomic disparities may vary between developing and developed nations.
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