Social Defeat and Psychotic Experiences in the United States: Findings from the Collaborative Psychiatric Epidemiological Surveys

Hans Oh

Submitted in partial fulfillment of the requirements for the Doctor of Philosophy under the Executive Committee of the Graduate school of Arts and Sciences

COLUMBIA UNIVERSITY

2015

ABSTRACT

Social Defeat and Psychotic Experiences in the United States: Findings from the Collaborative Psychiatric Epidemiological Surveys

Hans Oh

Emerging studies have identified a specific kind of stress called social defeat, which occurs when a person is dominated, humiliated, and oppressed by another person or group. The sense of social defeat might play an important role in the development of psychosis. Meanwhile, scholars have increasingly studied the occurrence of Psychotic Experiences, which are expressions of psychosis that manifest in the general population without causing significant distress or functional impairment. Very few studies have examined the relationship between social defeat and Psychotic Experiences in the United States, and I utilize the Collaborative Psychiatric Epidemiological Surveys to examine whether and to what extent three facets of social defeat (everyday discrimination, major discriminatory events, and immigrant status) predict risk for Psychotic Experiences. In the first paper, I analyzed the National Latino and Asian American Survey and the National Survey of American Life, and found that among Latino-, Asian-, and Black- Americans, everyday discrimination was associated with increased risk for Psychotic Experiences in a dose-response fashion after adjusting for demographics and socioeconomic status. Discrimination perpetrated at the interpersonal level seems to impart a profound sense of defeat that raises risk for psychosis. In the second paper, I analyzed the National Survey of American Life and found that among Black Americans, certain major discriminatory events (being denied a loan, receiving unusually bad service, and police abuse) were associated with increased risk for Psychotic Experiences after controlling for demographics and socioeconomic status. Major events seem to capture a distal source of distress stemming from the institutions and structures of society, elevating risk for psychosis among Black Americans. In the final paper, I examined the National Comorbidity Survey Replication, the National Latino and Asian American Survey, and the National Survey of American Life, and found that immigration was not associated with increased risk for Psychotic Experiences in the United States, supporting the extant literature that suggests immigrants are paradoxically healthier than native-born populations. I discuss theoretical and practical implications of my findings, and present future directions for research.

Table of Contents

List of Tables and Figures iii

Chapter I: Introduction

Psychotic Experiences 1

Social Defeat 2

Discrimination 3

Immigration 4

References 6

Chapter II: Perceived discrimination and psychotic experiences across multiple ethnic groups in the United States

Introduction 11

Methods 13

Results 17

Discussion 23

References 28

Chapter III: Major discriminatory events are associated with increased risk for psychotic experiences among Black Americans

Introduction 37

Methods 44

Results 49

Discussion 54

References 57

Chapter IV: Immigration and psychotic experiences in the United States: Another example of the epidemiological paradox?

Introduction 68

Methods 75

Results 78

Discussion 87

References 94

Chapter V: Conclusion

Summary and Discussion of Results 106

Potential Limitations and Future Directions 107

Implications for social work practice 108

References 110

APPENDICES 112

Tables and Figures

Chapter 1 Figure 1. Psychosis Continuum 1

Chapter 2 Table 1. Descriptive and bivariate comparisons of demographic and clinical variables 18 between respondents with and without PE

Table 2. Descriptive and bivariate comparisons of discriminatory experiences between 19 respondents with and without PE

Table 3. Multiple logistic regression models of associations between lifetime PE and 21 discrimination and covariates

Figure 1. Discrimination and psychotic experience subtypes 22

Chapter 3 Table 1. Descriptive statistics of major discriminatory events and psychotic experiences 49 using completed cases

Table 2. Descriptive statistics of major discriminatory events and subtypes of PE using 50 completed cases

Table 3. Descriptive statistics of range of discriminatory events and psychotic experience 51 subtypes by ethnicity using completed cases

Table 4. Bi-variable and adjusted logistic regression models depicting the impact of each 52 major discriminatory event on lifetime and 12-month psychotic experiences using completed cases

Table 5. Bi-variable and adjusted logistic regression models depicting the impact of each 53 major discriminatory event on subtypes of psychotic experiences using completed cases

Table 6. Adjusted logistic regression models depicting the associations between range of 54 general discrimination and PE using completed cases

Chapter 4 Table 1. Descriptive data for migration variables and PE for each data set 79

Table 2. Demographic variables by each data set 80

Table 3. Multivariable logistic regression models depicting associations between 82 generational status and psychotic experiences in the National Comorbidity Survey -

iii

Replication

Table 4. Multivariable logistical regression models depicting associations between 84 immigration and lifetime psychotic experiences among Latinos (N=2539) in the National Latino and Asian American Survey

Table 5. Multivariable logistical regression models depicting associations between 85 immigration and lifetime psychotic experiences among Asians (N=2089) in the National Latino and Asian American Survey

Table 6. Multivariable logistic regression models depicting associations between nativity 87 and lifetime psychotic experiences among Black Americans (N=4906) in the National Survey of American Life

ACKNOWLEDGEMENTS

I owe a debt of gratitude to many individuals for helping me complete this dissertation.

Specifically, I would like to thank Ellen Lukens for sponsoring me, and Ada Mui for chairing my committee. I would also like to thank Fang-pei Chen, Jennifer Abe, and Jordan DeVylder for serving as committee members. Lastly, I would like to thank my family and friends for their love and support.

DEDICATION

This is what the LORD says: Do what is just and right. Rescue from the hand of the oppressor the one who has been robbed. Do no wrong or violence to the foreigner, the fatherless or the widow, and do not shed innocent blood in this place. Jeremiah 22:3.

Chapter I: Introduction

Our understanding of psychosis has evolved over the past few decades into what we now conceptualize as a continuous phenotype that extends across a range of expressions. On the most severe end of the continuum is psychotic disorder, which causes significant distress and impairment in functioning. An example of a psychotic disorder is schizophrenia, which is rare and only occurs in about 1% of the US population. The middle region of the continuum consists of persistent psychotic symptoms, often emerging as features of non-psychotic mental illnesses.

On the least severe end of the continuum are psychotic experiences (PE), which are attenuated hallucinations or delusions reported by ‘healthy’ people. PE are far more common than psychotic disorders and occur in upwards of 7.2% of the US population (Linscott & van Os, 2013).

Most of the time PE are fleeting and innocuous; however, they do raise concerns. About

8-10% of those who report PE will develop a psychotic or non-psychotic disorder each year

(Kaymaz et al., 2012), meaning PE have some predictive utility (Fisher et al., 2013; Werbeloff et al., 2012). Further, people with PE seem to seek treatment and perceive the need for help more than those who do not report PE (Armando et al., 2010; DeVylder et al., 2014a; Murphy et al.,

2010; Oh et al., 2014; Yung et al., 2006), though distress associated with PE does not necessarily predict transition into disorder (Power et al., 2015). PE also co-occur with other psychiatric disorders (DeVylder et al., 2014), and are associated with suicide attempts among those with suicidal ideation (DeVylder et al., 2015). These negative outcomes compel researchers to examine the factors that increase risk for PE, and how these factors might inform prevention and early interventions.

Proneness Persistence Impairment (Experiences) (Symptoms) (Disorders)

Figure 1. The Psychosis Continuum

Social defeat stress

The diathesis-stress model posits that individual predisposition for illness –such as biological or genetic traits –interacts with environmental stressors to produce mental illness

(Walker & Diforio, 1997). The biological processes by which stress can impact health are complex, but one possible pathway is via the hypothalamic-pituitary-adrenal (HPA) axis –an intricate set of interactions among three endocrine glands that work together to help humans mobilize resources and respond to stress. Repeated activation of the HPA axis, however, can result in the excessive production of cortisol, which over time can damage regions of the brain

(such as the hippocampus and the prefrontal cortex) that regulate hormone transmission, leading to increased vulnerability to mental illness (Walker 2008; Corcoran, 2003).

Social defeat is a particular type of stress that was first observed in laboratory animals

(mice, pigs, and macaques) but may affect humans as well (see Bjorkqvist, 2001). Scientists noted that when pitting two territorial male mice against each other, the defeated mouse would begin to undergo changes in his cardiovascular, endocrine, and immune systems. Even just one experience of defeat seemed to disrupt the mouse’s hormone and neurotransmitter responses, resulting in behaviors that resembled depression, fear, sleep disturbance, and even addiction.

Similarly, based on observational studies conducted in colleges, prisons, and workplaces, people who feel defeat can sustain physiological and psychological injuries. An example of this would be victims of bullying, who often exhibit low self-esteem, loneliness, depression, anxiety, and social isolation.

Researchers believe that social defeat may play a significant role in the onset and exacerbation of psychosis (Selten & Cantor-Graae, 2005; 2007). In theory, chronic exposure to social defeat can dysregulate dopamine production, which impacts the mesolimbic region of the

brain, where hallucinations and delusions originate. The aberrant salience model (Kapur, 2003;

Howes & Kapur, 2009) posits that chaotic dopamine transmission might cause a person’s brain to inappropriately process stimuli, drawing the person’s attention to things that he or she would normally overlook, or leading the person to attribute meanings to things that are irrelevant

(Roiser et al., 2013). Aberrant salience can occur at the sub-threshold level, and may play a critical role in how social defeat and discrimination precipitate PE.

Discrimination as a contributor to social defeat

Discrimination contributes to a sense of social defeat by increasing feelings of subordination and exclusion. Racial and ethnic minorities are highly likely to encounter discrimination, which according to the social defeat hypothesis may explain why the incidence of schizophrenia is elevated among them (Sharpley et al., 2001; Fearon et al., 2006; Veling et al.,

2006), and why perceived disadvantage has been connected to risk for psychosis among Black ethnic groups in the UK (Cooper et al., 2008; Reininghaus et al., 2010). But discrimination is a broad concept that needs to be unpacked and contextualized. Much of the research that examines the relationship between discrimination and psychosis has used simple measures of discrimination and has been conducted in Europe. More studies are needed using stronger measures of discrimination and PE in the US context, where racism is long-standing and pervasive.

In the US, discrimination is multifaceted and occurs at multiple levels, from the individual to the structural (Jones, 2000). That is, discrimination can be perpetrated at an interpersonal level, but can also be inflicted through institutions, structures, and social forces in the interest of the dominant group while oppressing minority groups (Powell, 2008). Awareness of social inequities can make social defeat more potent (see Harrell, 2011). Everyday discrimination

has been shown to increase risk for psychotic disorders and sub-threshold symptoms in Europe, but more research is needed to confirm this association in the United States. Major discriminatory events should also increase risk for psychotic experiences, but empirical verification is needed.

Immigration

Immigrants are vulnerable to discrimination, and tend to report increased risk for psychotic disorder and psychotic experiences in Europe. However, no evidence of this relationship exists in the US, though one study showed that amongst immigrants, acculturative stress increases risk for PE (DeVylder et al., 2013). Little is known about whether or not immigrants –who have often proven to be resilient to mental health problems –are at greater risk for PE when compared with native-born populations. In fact, one study showed that first- generation Mexican immigrants were less likely to report psychotic symptoms, which would ostensibly contradict the social defeat hypothesis (Vega et al., 2006). Throughout much of US history, the dominant white society espoused the view that other races and ethnicities were inferior, diseased, and morally bankrupt (Barkan et al., 2008; Park, 2004), leading to xenophobic restrictions on immigration as well as the deportation of those already residing in the country.

Further, immigrants were often screened for sickness and illiteracy before being permitted into the country. This might have ironically caused a selection effect that resulted in higher health status among immigrants.

Aims

In this dissertation, I will examine the relationship between social defeat and psychotic experiences in the United States by analyzing data from the Collaborative Epidemiological

Surveys, which is comprised of the following surveys:

1. The National Comorbidity Survey (NCS-R; Kessler et al., 2004): a nationally

representative survey, predominantly White respondents, reflecting the general

population.

2. The National Latino and Asian American Survey (NLAAS; Alegria et al., 2004): a

household survey of Asians and Latinos.

3. The National Survey of American Life (NSAL; Jackson et al., 2004): a nationally

representative sample of African American households with Black Caribbean

respondents drawn from the same source neighborhoods.

This dissertation will consist of three independent but related papers addressing how the discrimination and exclusion that characterize social defeat is associated with PE. Paper 1 focuses on the associations between everyday discrimination and PE among racial/ethnic minorities (NLAAS & NSAL); Paper 2 focuses on the associations between major discriminatory events and PE among Black Americans (NSAL); and Paper 3 focuses on the associations between immigrant status and PE among a racially/ethnically diverse sample (NCS-

R, NLAAS, & NSAL). I conclude with directions for future research and implications for social work practice.

References

Alegria, M., Jackson, J. S., Kessler, R. C., & Takeuchi, D. (2007). Collaborative Psychiatric

Epidemiology Surveys (CPES), 2001–2003 [United States]. Computer file ICPSR20240-

v5. Ann Arbor, MI: Institute for Social Research, Survey Research Center [producer].

Armando, M., Nelson, B., Yung, A. R., Ross, M., Birchwood, M., Girardi, P., & Nastro, P. F.

(2010). Psychotic-like experiences and correlation with distress and depressive symptoms

in a community sample of adolescents and young adults. Schizophrenia Research, 119(1),

258–265.

Barkan, E., Diner, H. R., & Kraut, A. (2007). From arrival to incorporation: migrants to the US

in a global era. NYU Press. Retrieved from

http://books.google.com/books?hl=en&lr=&id=rodTDgem8oYC&oi=fnd&pg=PR7&dq=

Arrival+to+Incorporation:+Migrants+to+the+US+in+a+Global+Era+&ots=qSpJWjzjGu

&sig=kvRPf2e228BEM6KdNlgVpZXT19c

Björkqvist, K. (2001). Social defeat as a stressor in humans. Physiology & Behavior, 73(3), 435–

442.

Cooper, C., Morgan, C., Byrne, M., Dazzan, P., Morgan, K., Hutchinson, G., … Jones, P. (2008).

Perceptions of disadvantage, ethnicity and psychosis. The British Journal of Psychiatry,

192(3), 185–190.

Corcoran, C., Walker, E., Huot, R., Mittal, V., Tessner, K., Kestler, L., & Malaspina, D. (2003).

The stress cascade and schizophrenia: etiology and onset. Schizophrenia Bulletin, 29(4),

671–692.

DeVylder, J. E., Burnette, D., & Yang, L. H. (2014). Co-occurrence of psychotic experiences

and common mental health conditions across four racially and ethnically diverse

population samples. Psychological Medicine, 44(16), 3503–3513.

DeVylder, J. E., Lukens, E. P., Link, B. G., & Lieberman, J. A. (2015). Suicidal ideation and

suicide attempts among adults with psychotic experiences: data from the Collaborative

Psychiatric Epidemiology Surveys. JAMA Psychiatry, 72(3), 219–225.

DeVylder, J. E., Oh, H. Y., Corcoran, C. M., & Lukens, E. P. (2014). Treatment Seeking and

Unmet Need for Care Among Persons Reporting Psychosis-Like Experiences.

Psychiatric Services. Retrieved from

http://journals.psychiatryonline.org/article.aspx?articleid=1832054

DeVylder, J. E., Oh, H. Y., Yang, L. H., Cabassa, L. J., Chen, F., & Lukens, E. P. (2013).

Acculturative stress and psychotic-like experiences among Asian and Latino immigrants

to the United States. Schizophrenia Research, 150(1), 223–228.

DeVylder, J. E., Thompson, E., Reeves, G., & Schiffman, J. (2015). Psychotic experiences as

indicators of suicidal ideation in a non-clinical college sample. Psychiatry Research,

226(2), 489–493.

Fearon, P., Kirkbride, J. B., Morgan, C., Dazzan, P., Morgan, K., Lloyd, T., … Holloway, J.

(2006). Incidence of schizophrenia and other psychoses in ethnic minority groups: results

from the MRC AESOP Study. Psychological Medicine, 36(11), 1541–1550.

Fisher, H. L., Caspi, A., Poulton, R., Meier, M. H., Houts, R., Harrington, H., … Moffitt, T. E.

(2013). Specificity of childhood psychotic symptoms for predicting schizophrenia by 38

years of age: a birth cohort study. Psychological Medicine, 43(10), 2077–2086.

Harrell, C. J. P., Burford, T. I., Cage, B. N., Nelson, T. M., Shearon, S., Thompson, A., & Green,

S. (2011). Multiple pathways linking racism to health outcomes. Du Bois Review: Social

Science Research on Race, 8(01), 143–157.

Howes, O. D., & Kapur, S. (2009). The dopamine hypothesis of schizophrenia: version III—the

final common pathway. Schizophrenia Bulletin, 35(3), 549–562.

Jackson, J. S., Torres, M., Caldwell, C. H., Neighbors, H. W., Nesse, R. M., Taylor, R. J., …

Williams, D. R. (2004). The National Survey of American Life: a study of racial, ethnic

and cultural influences on mental disorders and mental health. International Journal of

Methods in Psychiatric Research, 13(4), 196–207.

Jones, C. P. (2000). Levels of racism: a theoretic framework and a gardener’s tale. American

Journal of Public Health, 90(8), 1212.

Kapur, S. (2003). Psychosis as a state of aberrant salience: a framework linking biology,

phenomenology, and pharmacology in schizophrenia. American Journal of Psychiatry,

160(1), 13–23.

Kaymaz, N., Drukker, M., Lieb, R., Wittchen, H. U., Werbeloff, N., Weiser, M., … Van Os, J.

(2012). Do subthreshold psychotic experiences predict clinical outcomes in unselected

non-help-seeking population-based samples? A systematic review and meta-analysis,

enriched with new results. Psychological Medicine, 42(11), 2239.

Kessler, R. C., & Üstün, T. B. (2004). The world mental health (WMH) survey initiative version

of the world health organization (WHO) composite international diagnostic interview

(CIDI). International Journal of Methods in Psychiatric Research, 13(2), 93–121.

Linscott, R. J., & Van Os, J. (2013). An updated and conservative systematic review and meta-

analysis of epidemiological evidence on psychotic experiences in children and adults: on

the pathway from proneness to persistence to dimensional expression across mental

disorders. Psychological Medicine, 43(06), 1133–1149.

Murphy, J., Shevlin, M., Houston, J., & Adamson, G. (2010). A population based analysis of

subclinical psychosis and help-seeking behavior. Schizophrenia Bulletin, sbq092.

Oh, H., DeVylder, J. E., & Chen, F. (2014). To Treat or Not to Treat: Responding to Psychotic

Experiences. British Journal of Social Work, bct199.

Park, J. S. (2004). Elusive citizenship: Immigration, Asian Americans, and the paradox of civil

rights. NYU Press. Retrieved from

http://books.google.com/books?hl=en&lr=&id=4nyggcWumFoC&oi=fnd&pg=PR11&dq

=Elusive+Citizenship:+Immigration,+Asian+Americans,+and+the+Paradox+of+Civil+Ri

ghts&ots=YpITibT-Q4&sig=Tsw1_WNypdxKroRXm7ltW-VQruI

Powell, J. A. (2007). Structural racism: building upon the insights of John Calmore. NCL Rev.,

86, 791.

Power, L., Polari, A. R., Yung, A. R., McGorry, P. D., & Nelson, B. (2015). Distress in relation

to attenuated psychotic symptoms in the ultra-high-risk population is not associated with

increased risk of psychotic disorder. Early Intervention in Psychiatry. Retrieved from

http://onlinelibrary.wiley.com/doi/10.1111/eip.12233/full

Reininghaus, U., Craig, T. K., Fisher, H. L., Hutchinson, G., Fearon, P., Morgan, K., … others.

(2010). Ethnic identity, perceptions of disadvantage, and psychosis: Findings from the

ÆSOP study. Schizophrenia Research, 124(1), 43–48.

Roiser, J. P., Howes, O. D., Chaddock, C. A., Joyce, E. M., & McGuire, P. (2013). Neural and

behavioral correlates of aberrant salience in individuals at risk for psychosis.

Schizophrenia Bulletin, 39(6), 1328–1336.

Selten, J.-P., & Cantor-Graae, E. (2005). Social defeat: risk factor for schizophrenia? The British

Journal of Psychiatry, 187(2), 101–102.

SHARPLEY, M. S., Hutchinson, G., MURRAY, R. M., & McKenzie, K. (2001). Understanding

the excess of psychosis among the African—Caribbean population in England Review of

current hypotheses. The British Journal of Psychiatry, 178(40), s60–s68.

Vega, W. A., Sribney, W. M., Miskimen, T. M., Escobar, J. I., & Aguilar-Gaxiola, S. (2006).

Putative psychotic symptoms in the Mexican American population: prevalence and co-

occurrence with psychiatric disorders. The Journal of Nervous and Mental Disease,

194(7), 471–477.

Veling, W., Selten, J.-P., Veen, N., Laan, W., Blom, J. D., & Hoek, H. W. (2006). Incidence of

schizophrenia among ethnic minorities in the Netherlands: a four-year first-contact study.

Schizophrenia Research, 86(1), 189–193.

Walker, E. F., & Diforio, D. (1997). Schizophrenia: a neural diathesis-stress model.

Psychological Review, 104(4), 667.

Walker, E., Mittal, V., & Tessner, K. (2008). Stress and the hypothalamic pituitary adrenal axis

in the developmental course of schizophrenia. Annu. Rev. Clin. Psychol., 4, 189–216.

Werbeloff, N., Drukker, M., Dohrenwend, B. P., Levav, I., Yoffe, R., van Os, J., … Weiser, M.

(2012). Self-reported attenuated psychotic symptoms as forerunners of severe mental

disorders later in life. Archives of General Psychiatry, 69(5), 467–475.

Yung, A. R., Buckby, J. A., Cotton, S. M., Cosgrave, E. M., Killackey, E. J., Stanford, C., …

McGorry, P. D. (2006). Psychotic-like experiences in nonpsychotic help-seekers:

associations with distress, depression, and disability. Schizophrenia Bulletin, 32(2), 352–

359.

Chapter II: Perceived discrimination and psychotic experiences across multiple ethnic groups in the United States

Introduction

Exposure to discrimination is a common experience for socially disadvantaged groups in the United States, and has been associated with increased probability of mental illness (Pascoe and Richman, 2009; Wamala et al. 2007). Environmental stressors such as discrimination are associated with subordinate or outside status and contribute to a sense of “social defeat” (Selten and Cantor-Graae, 2005; 2007), which may be particularly relevant to the onset and exacerbation of psychotic symptoms among vulnerable individuals (Corcoran et al., 2003). In accordance with the social defeat hypothesis, incidence of schizophrenia is high amongst certain immigrant and ethnic minority groups (Cantor-Graae et al., 2005; Fearon et al., 2006; Sharpley et al., 2001;

Veling et al., 2006).

Population-based studies from Europe have found that perceived discrimination in general is associated with the increased likelihood of reporting psychosis (Cooper et al., 2008;

Veling, 2013; Veling et al., 2007), with discriminatory verbal abuse increasing the odds of psychosis by as much as two to three fold, and discriminatory physical attacks increasing the odds of psychosis by three to five fold when compared with those who did not report experiences of discrimination (Karlsen and Nazroo, 2002; Karlsen et al., 2005). Veling and colleagues (2007) likewise found that the incidence rate for psychotic disorders was highest among ethnic groups that reported the most severe discrimination at the group level, although this was not replicated when examining individual-level perceived discrimination in a subsequent case-control study

(Veling et al., 2008).

Psychotic disorders are stigmatized conditions, often characterized by experiences of persecution and mistreatment (Thornicroft et al., 2009). As such, perceived discrimination may be a consequence rather than a cause of psychotic disorders. It is therefore useful to examine the associations between discrimination and the sub-threshold range of the psychosis continuum

(van Os et al., 2009), where the absence of a ‘psychosis’ label may make reverse causality less likely.

Janssen and colleagues (2003) examined the relationship between discrimination and psychotic experiences (PE) by analyzing data from The Netherlands Mental Health Survey and

Incidence Study (NEMESIS) –a longitudinal random population sample of 7076 adult respondents, who were asked (yes/no) if they had experienced discrimination on the basis of their skin color/ethnicity, gender, age, appearance, disability, or sexual orientation within the past year. The authors found perceived discrimination to be associated with the onset of delusional ideation but not hallucinatory experiences, possibly reflecting effects of chronic discrimination on cognitive attributions of daily events (Gilvarry et al., 1999; Sharpley & Peters,

1999; Bentall et al., 2001). However, endorsement of discrimination items was uncommon in their study and primarily consisted of age (6%) and gender (4%) discrimination. It is therefore unclear whether and to what extent these findings would generalize to individuals who experience more persistent forms of discrimination, which at severe levels can be traumatic

(Carter, 2007; 2010) and thus possibly lead to hallucinations (Kilcommons & Morrison, 2005;

Morrison & Petersen, 2003).

In this paper, I examine the relationship between perceived discrimination and psychotic symptoms in a racially- and ethnically-diverse population-level sample from the United States

(US). To my knowledge, this is the first study to examine this relationship using a validated

measure of perceived discrimination that captures the frequency and range of day-to-day discriminatory experiences in the general population. I expected to see associations between discrimination and delusions (Janssen et al., 2003), but given the greater overall prevalence and severity of perceived discrimination in my sample, I also expected to see associations between discrimination and hallucinations as well.

Methods

Sample and procedures

This paper analyzed data from the National Latino and Asian American Survey (NLAAS)

(Alegria et al., 2004) and the National Survey of American Life (NSAL) (Jackson et al., 2004), which were conducted between the years 2001 and 2003 using the World Health Organization

Composite International Diagnostic Interview (WHO CIDI; Kessler and Ustun, 2004). These two datasets were amalgamated for the purposes of this analysis. The study population included non- institutionalized adults over the age of 18 who were selected through a multistage probability sampling strategy to achieve nationally representative samples of Asians, Latinos, and African

Americans living in the United States (Heeringa et al., 2004). Special supplements were used to oversample from census block groups with high-density of individuals of Puerto Rican, Cuban,

Chinese, Filipino, Vietnamese, and Caribbean national origin (Heeringa et al., 2004). Non-

Hispanic whites in the NSAL (N=891) were omitted from this analysis.

The response rate for the NLAAS was 75.7% (77.6% for Latinos, 69.3% for Asians) for the main respondents, and 80.3% (82.4% for Latinos, 73.7% for Asians) for the second respondents (Heeringa et al., 2004). The response rate for the core NSAL sample was 71.5%

(76.4% for the Caribbean supplement sample). Details on the sampling strategy and interview

procedures have been described in depth elsewhere (see Heeringa et al., 2004; Pennell et al.,

2004; Alegria et al., 2004; Jackson et al., 2004). The analytic sample consisted of 8990 participants, 1945 of which were Asian, 2551 of which were Hispanic, 3200 of which were

African American, and 1294 of which were Afro-Caribbean American. The survey investigators provided survey weighting (NSNLWT) and stratification (SESTRAT) variables to allow for the analysis of the combined datasets (Heergina et al., 2007).

Measures

The WHO-CIDI 3.0 Psychosis Screen

Respondents were asked to report the lifetime presence of six specific PE from the WHO-

CIDI 3.0 psychosis screen, including: 1) visual hallucinations, 2) auditory hallucinations, 3) thought insertion, 4) thought control, 5) telepathy, 6) delusions of persecution. Respondents that positively endorsed any of these items were then asked if the experience had occurred in the past

12 months. The WHO-CIDI psychosis screen is a common measure of PE and has been validated through associations with hospital admissions and the development of full psychotic disorder in a dose-response fashion (Kaymaz et al., 2012). Responses were not considered a PE if the experience took place in the context of falling asleep, dreaming, or substance use. Thought insertion, thought control, telepathy, and delusions of persecution constituted the delusion subtype.

A clinical reappraisal study revealed that most individuals (93%) with PE in the NLAAS dataset did not meet criteria for psychotic disorder (Lewis Fernandez et al., 2009). To my knowledge, no clinical reappraisal study has been published for the NSAL, and relevant data were not released to the public. The schizophrenia diagnosis was only available through self- report and thus did not serve as an exclusion criterion in the primary analyses, meaning my

analyses may have included some individuals with clinical psychosis. I conducted additional analyses with the exclusion of people who self-reported schizophrenia and discussed the findings below.

The Everyday Discrimination Scale

Perceived discrimination was measured using the Everyday Discrimination Scale (EDS) of the Detroit Area Study Discrimination Questionnaire, which aggregated perceptions of routine discrimination over the course of an individual’s lifetime (Williams et al., 1997). This has been validated as a reliable measure of perceived discrimination (Krieger et al., 2005) and has been used to study African Americans (Taylor et al., 2004), Hispanic-Americans (Sribney and

Rodriguez, 2009; Fortuna et al., 2008), and Asian-Americans (Gee et al., 2007). Participants were asked, “In your day-to-day life, how often have any of the following things happened to you?” Then participants were asked to rate the frequency of nine discriminatory events using following responses: almost everyday, at least once a week, a few times a month, a few times a year, less than once a year, or never (Table 2). A subsample of participants indicated the main reason that they believed was the basis of the discrimination by selecting from a fixed list of attributions, including ancestry/national origin/ethnicity, gender/sex, race, age, height/weight, skin color, and other. The Cronbach alpha for the overall sample was 0.90 (NLAAS: 0.91;

NSAL: 0.88). Studies of victimization have suggested that the perceived severity of social stressors has greater influence of risk for psychotic experiences than the objective severity

(Groman et al., 2013).

Covariates

Demographic covariates included age, gender, education, immigration status, and race, all of which were self-reported by participants as part of the WHO-CIDI battery. Clinical

diagnoses of interest included substance use (alcohol abuse, alcohol dependence, drug abuse, or drug dependence) and post-traumatic stress disorder (PTSD). Social isolation and urbanicity are risk factors for psychosis that are also associated with discrimination; however, these variables were not available in the public version of the datasets. Instead, I controlled for social interaction using the use the WHO Disability Assessment Schedule, and I controlled for region (Northeast,

Midwest, South, West) and income-to-poverty ratio, which tend to correlate with urbanicity.

Analysis

All analyses were performed using STATA SE version 13. The EDS items were summed into a continuous scale ranging from 0-45, which was used in sensitivity analyses to test whether findings were robust even when discrimination was coded a few different ways. However, given the skewed distribution of the sample and the possibility of a non-linear relationship between discrimination and PE, the scale was discretized into five categories (0, 1-6, 7-10, 11-15, and 16-

45) that each consisted of roughly 20% of the sample, similar to the approach used by Kessler and colleagues (1999) in the development of the EDS. A score of zero signified no experiences of discrimination and served as the reference group. Separate unadjusted and adjusted multivariable logistic regression models were used, first to examine the crude bivariate relationship between perceived discrimination and PE, and second to examine the relationship adjusting for demographic variables and clinical diagnoses. Effect sizes for all logistic regression models were presented as odds ratios (OR) with 95% confidence intervals (CI). Adjusted logistic regression models were used to examine the relationship between perceived discrimination and specific sub-types of PE (auditory and visual hallucinatory experiences, and delusional ideation).

Results

The sample

Approximately 87% of the total sample responded to both the perceived discrimination and psychotic experience items. The total analytic sample consisted of 8990 individuals, 9.39% of which reported a psychotic experience. Univariate Wald chi-square analyses revealed that those with PE were more likely to be poor, born in the U.S., African-American, have a substance use problem, have PTSD, and have impairment in social interactions. Those with PE were less likely to be Asian and less likely to be from the South (Table 1). 79.01% of the analytic sample reported experiencing some form of discrimination in their day to today life. Just over 18% of the sample reported perceiving one or more kinds of discrimination on at least a weekly basis

(Table 2). 6226 respondents who endorsed perceived discrimination gave reasons that they believed were the basis of the discrimination. The majority of these participants attributed discriminatory experiences to their race (64.87% SE: 1.29), followed by other reasons (23.1%

SE: 0.97), height or weight (2.35% SE: 0.20), gender (3.7% SE: 0.29), and age (5.99% SE: 0.57).

Table 1. Descriptive and bivariate comparisons of demographic and clinical variables between respondents with and without PE Characteristic Total (n=8990) No PE (n=8138) PE (n=852) Wald X2 Age (years) 18-29 30.12 (1.02) 30.00 (1.11) 31.32 (1.81) 0.39, p=0.531 30-44 35.91 (0.72) 36.17 (0.76) 33.44 (1.76) 2.10, p=0.150 45-59 20.89 (0.65) 20.73 (0.70) 22.37 (1.79) 0.75, p=0.388 60+ 13.08 (0.60) 13.10 (0.60) 12.87 (1.78) 0.02, p=0.896 Gender Male 48.17 (0.61) 48.33 (0.65) 46.66 (2.00) 0.62, p=0.433 Female 51.83 (0.61) 51.67 (0.65) 53.34 (2.00) Income-to-poverty 0 (poor)* 12.69 (0.82) 12.24 (0.78) 17.04 (2.11) 9.19, p=0.003 1-2 40.63 (0.93) 40.41 (1.02) 42.78 (2.76) 0.61, p=0.437 3+ (non-poor)* 46.67 (1.29) 47.35 (1.34) 40.18 (2.83) 6.08, p=0.015 Education (years) 0-11 31.2 (1.29) 31.27 (1.43) 30.59 (2.14) 0.06, p=0.803 12 28.75 (0.78) 28.92 (0.82) 27.12 (2.09) 0.66, p=0.419 13-15* 22.66 (0.76) 22.18 (0.85) 27.37 (2.20) 4.74, p=0.031 16+ 17.38 (0.93) 17.64 (0.99) 14.92 (1.81) 1.72, p=0.192 Immigrant Status Immigrant* 40.13 (1.66) 41.32 (1.73) 28.60 (2.57) 18.59, p=0.000 Native Born 59.87 (1.66) 58.68 (1.73) 71.40 (2.57) Race Asian* 15.98 (1.26) 16.53 (1.34) 10.72 (1.12) 18.47, p=0.000 Hispanic 44.06 (2.37) 44.37 (2.46) 41.10 (2.87) 1.42, p=0.236 Af Carib 2.35 (0.18) 2.32 (0.19) 2.66 (0.52) 0.42, p=0.520 Af Am* 37.6 (2.02) 36.78 (2.07) 45.51 (2.96) 9.60, p=0.002 Clinical Diagnoses Substance Use* 9.74 (0.64) 8.75 (0.54) 19.25 (2.85) 26.96, p=0.000 PTSD* 5.75 (0.35) 4.84 (0.36) 14.58 (1.44) 74.43, p=0.000 Region Northeast 16.74 (1.09) 16.62 (1.14) 17.82 (2.03) 0.33, p=0.567 Midwest 11.81 (1.09) 11.41 (1.09) 15.65 (2.82) 2.87, p=0.093 South* 37.32 (2.65) 37.95 (2.75) 30.23 (2.67) 8.63, p=0.004 West 34.23 (2.59) 34.02 (2.66) 36.30 (3.17) 0.70, p=0.405 Disability Social Interaction* 5.52 (0.39) 4.57 (0.37) 14.68 (1.67) 76.80, p=0.000 Weighted percentages and standard errors are adjusted for complex survey design. For all Wald Chi Square Tests, df=1. *denotes significance, p<0.05

Table 2. Descriptive and bivariate comparisons of discriminatory experiences between respondents with and without PE Discriminatory Experience Total No PE PE Wald X2 You are treated with less courtesy than other 7.56 (0.44) 6.93 (0.42) 13.63 (1.59) 28.15, p=0.000 people* You are treated with less respect than other 5.93 (0.34) 5.44 (0.34) 10.69 (1.73) 13.77, p=0.000 people* You receive poorer service than other people 3.28 (0.29) 2.96 (0.29) 6.39 (1.37) 9.78, p=0.002 at restaurants or stores* People act as if they think you are not smart* 7.20 (0.52) 6.20 (0.50) 16.91 (2.11) 45.59, p=0.000 People act as if they are afraid of you* 3.63 (0.30) 3.00 (0.28) 9.66 (1.49) 41.23, p=0.000 People act as if you are not as good as they 9.75 (0.59) 8.67 (0.62) 20.19 (2.22) 34.34, p=0.000 are* People act as if they think you are dishonest* 3.63 (3.00) 3.0 (0.28) 9.66 (1.49) 41.23, p=0.000 You are called names or insulted* 3.57 (0.33) 3.16 (0.35) 7.60 (1.34) 16.42, p=0.000 You are threatened or harassed 1.34 (0.17) 1.25 (0.18) 2.17 (0.68) 2.38, p=0.1253 Any of the above* 18.48 (0.80) 16.79 (0.79) 34.84 (2.67) 55.97, p=0.000 % (SE) of individuals who reported experiencing the discriminatory event at least once a week or more. Weighted percentages and standard errors are adjusted for complex survey design. For all Wald Chi Square Tests, df=1. *denotes significance, p<0.05

Regression models

When compared with those who have never experienced discrimination, individuals in the highest frequency of discrimination category (the top 20% of individuals who scored 16 or higher on the 0-45 discrimination scale, herein referred to has the ‘high’ discrimination category) were over three times more likely to report PE, both lifetime and 12-month, adjusting for demographic covariates and clinical disorders (Table 3). The five categories of discrimination were combined into a single ordinal variable in order to conduct a linear trend test, which confirmed that the odds of PE increased with greater exposure to discrimination (z=12.22, p<0.001).

When compared with the non-poor, individuals below the poverty line were almost 70% more likely to report a lifetime PE. Lifetime substance use increased the likelihood of lifetime

PE by 70%, and 12-month PE by over 60%. A lifetime diagnosis of PTSD was associated with a

two-fold increase in probability of reporting a lifetime PE, and over 80% increase in probability of 12-month PE. Any amount of impairment in social interaction increased risk of PE by over two-fold, both lifetime and 12-month. When compared with living in the West, living in the

South was associated with an approximately 40% decreased risk of lifetime PE and almost 50% decreased risk in 12-month PE.

The associations between discrimination and the specific subtypes of PE also revealed linear trends (Figure 1). When compared with those who never experienced discrimination, the high discrimination category was almost four times more likely to report a lifetime auditory hallucination, almost three times more likely to report a lifetime visual hallucination, and over four times more likely to report a lifetime delusion adjusting for demographic covariates and clinical disorders.

Table 3. Multiple logistic regression models of associations between lifetime PE and discrimination and covariates 12-Month Lifetime Discrimination (0-45) 16-45 (High) 4.959*** 3.257*** 4.197*** 3.262*** 11-15 2.383** 1.972** 2.642*** 2.432*** 7-10 1.863* 1.619+ 1.585 1.497 1-6 1.523 1.419 1.283 1.240 0 (Ref) 1.000 1.000 1.000 1.000 Age (Years) 18-29 (Ref) 1.000 1.000 30-44 0.979 0.973 45-59 0.956 1.199 60+ 0.856 1.443* Gender Female 1.319+ 1.104 Male (Ref) 1.000 1.000 Income-to-poverty ratio 0 (Poor) 1.352 1.686* 1-2 0.902 1.243 3+ (Nonpoor - Ref) 1.000 1.000 Education (Years) 0-11 (Ref) 1.000 1.000 12 0.715 0.955 13-15 0.700 1.239 16+ 0.767 1.035 Immigrant Status Immigrant 0.721+ 0.863 Native Born 1.000 1.000 Race Asian 0.569+ 0.714 Hispanic 1.008 0.984 Af Carib 1.345 0.968 Af Am 1.000 1.000 Clinical Diagnoses Substance Use 1.612** 1.705** PTSD 1.861** 2.055*** Region Northeast 0.725 0.850 Midwest 1.006 0.922 South 0.523** 0.608*** West 1.000 1.000 Disability Social Interaction 2.367*** 2.033*** Values indicate Odds Ratios; ***p<0.001, **p<0.01, *p<0.05, +p<0.10

Figure 1. Discrimination and psychotic experience subtypes Discrimination and psychotic experience subtypes

4.5 4.278

4 3.843 3.5 3.262 2.967 2.971 3 2.702 2.432 2.423 2.5 2.124 1 to 6 1.906 2 1.77 7 to 10 1.497 1.441 1.413 1.24 1.5 1.09 11 to 15 1 16 to 45

0.5 Psychotic Psychotic experiences (OR) 0 Total Auditory Visual Delusion Discrimination

Adjusted for age, gender, income-to-poverty ratio, education, immigration status, race, substance use, PTSD, region, social interaction, and complex survey design.

Additional Analyses

Recoding of the discrimination variable continuously or dichotomously did not affect major estimation of OR’s, in that more discrimination always signified greater likelihood of the presence of PE. In order to confirm my findings with respect to the sub-types of PE, I regressed perceived discrimination against auditory hallucinatory experiences after dropping all respondents who also reported visual hallucinatory experiences and delusional ideation (and similarly for the other sub-types), revealing linear trends comparable to my original models.

Also, in accordance with previous studies of PE using these data (DeVylder et al., 2013a), I dropped respondents with self-reported history of schizophrenia diagnosis from the analytic sample to eliminate the possibility that individuals with schizophrenia may be driving the

relationship between discrimination and PE. Effect sizes diminished slightly but not to a meaningful degree.

To account for the possibility that different attributions of discrimination can have distinctive effects, I ran additional analyses using the subsample of individuals who indicated a perceived reason for the discrimination (N=6225). I created an interaction variable between the continuous measure of discrimination and the attribution of discrimination (racial vs. nonracial); however, I did not detect any significant moderating effects. I then re-ran models stratifying for race, but my findings did not reveal effect modification.

Discussion

To my knowledge, this is the first study to analyze discrimination and PE among several large racially/ethnically diverse population-level samples based in the United States, using validated measures of discrimination. I found that perceiving discrimination at moderate to high levels predicts PE in a linear dose-response fashion. This expands Janssen and colleagues' (2003) study where endorsement of discrimination was minimal (approximately 12%), as opposed to my sample where discrimination was pervasive and frequent (80% endorsing at least some discrimination, 18% endorsing weekly discrimination or more). Further, Janssen and colleagues used a yes/no item to indicate the experience of discrimination; however, this study used a more comprehensive measure of discrimination, capturing the range and frequency of nine everyday discriminatory events.

The social defeat hypothesis suggests that being subordinated and humiliated can have a profound impact on the neurotransmitter and hormones that regulate brain functioning and behaviors, and other social stress models suggest behavioral sensitization to discriminatory

experiences may increase vulnerability to psychosis (Myin-Germeys et al., 2005; Selten and

Cantor-Graae, 2005; 2007; van Winkel et al., 2008). Studies have shown that this is also true for sub-threshold positive psychotic symptoms, including delusions as well as hallucinations

(DeVylder et al., 2013b). In accordance with my expectations, I found that discrimination predicted all subtypes of psychotic symptoms.

Prior studies of sub-threshold psychosis found discrimination to only predict delusional ideation (Janssen et al., 2003), or negative schemas (Saleem et al., 2013). Researchers have speculated that discrimination may elicit cognitive responses, such as paranoid attribution, that engender these delusional ideations. However, my analyses also found significant associations between perceived discrimination and hallucinatory experiences, possibly reflecting the effects of greater severity and frequency of discrimination in my sample. Conceivably, high levels of discrimination may take on a traumatic quality (Carter, 2007), leading to negative cognitions about the self, perceptual re-experiencing of trauma, or depersonalization, which may confer vulnerability to hallucinatory experiences (Kilcommons and Morrison, 2005).

Since my study is preliminary, I must acknowledge a number of potential limitations.

First, the items of the EDS may be difficult to differentiate from the paranoia and persecutory delusion screening items. However, since the majority of respondents with PE endorsed hallucinations, I can reasonably rule out collinearity given the minimal overlap between the constructs of perceived discrimination and hallucinations. I ran models looking at perceived discrimination and hallucinations only, and found that the associations persisted.

Second, as with all cross-sectional data, the observed associations may run in the reverse direction such that PE may cause greater perception of discrimination. While delusional ideations, particularly in the form of persecutory delusions, may potentially increase the

likelihood of perceiving discrimination, hallucinatory experiences are much less likely to do the same. Still, studies have shown that across the world, people with schizophrenia experience stigma (van Zelst, 2009) and increased exposure to discrimination (Thornicroft et al., 2009).

Individuals with PE by definition do not carry a diagnostic label and should thus be less susceptible to stigma and discrimination; however, it is worth mentioning that displaying characteristics consistent with psychosis risk (e.g. unusual thought content) may increase stigma regardless of a label (Anglin et al., 2013; Yang et al., 2010; Yang et al., 2013), or may elevate risk for other diagnostic labels (Fisher 2013).

Third, this study was unable to account for urbanicity, which has been associated with psychosis (Krabbendam and van Os, 2005; Kelly et al., 2010; Pedersen and Mortensen, 2001; van Os, 2004). Given the restrictions on the data, I only attempted to capture urbanicity indirectly through region and poverty, since the US census shows the West to be the most urbanized region of the country, and the South to be the most rural and impoverished (U.S.

Census Bureau, 2010; 2011). Studies should also take into account ethnic density, which can influence a number of mental and physical health outcomes (Becares et al., 2012; Syed and Juan,

2011), and can potentially buffer the association between racial/ethnic discrimination and psychotic experiences (Das-Munshi et al., 2012). For the present study, data on ethnic density was not available, and so I emulated Janssen and colleagues (2013) by examining both racial and non-racial discrimination.

My findings highlight the need to identify underlying pathways that might connect perceived discrimination with PE. I controlled for social interaction using the WHODAS and found that impairment in social functioning was a risk factor for PE; however, future research should use more comprehensive measures to examine whether and to what extent social

withdrawal serves as a conceptual mediator that connects discrimination to hallucinations and delusions, potentially by way of social deafferentation (Hoffman, 2007). In the same vain, I found that lifetime PTSD increased risk for PE; however, as stated earlier, trauma and adversity may play an important mediating role beyond serving merely as a confounding variable

(Hammer et al., 2000; Morgan et al., 2007; Read et al., 2005).

Another limitation of this study is its treatment of race as monolithic categories, as there was not sufficient statistical power to distinguish between the various ethnicities that constitute a racial category. Also, the PE measure may have captured culturally sanctioned experiences (i.e. cultural paranoia) instead of true delusional ideation or hallucinatory experiences. Indeed, paranoia may even represent a healthy coping strategy in a discriminatory environment (Sharpley et al., 2001). However, culturally sanctioned experiences only explained a minority of positive responses in a nationally-representative sample (Kessler et al., 2005). Future studies can test to see whether various social categories have differential vulnerabilities to discrimination and can explore whether the relationship between discrimination and PE is moderated by racial/ethnic identity or community affiliation.

PE may be clinically significant and may warrant treatment (Murphy et al., 2012;

DeVylder et al., 2014), thus it is important to detect and respond to PE with an appropriate and timely level of care (Oh et al., 2014). Identifying perceived discrimination as a potential risk factor for PE can inform prevention and intervention efforts to alleviate the stress associated with being in a subordinate or outsider status. Also, treatments for PE can utilize support groups that bring people of the same social category together, since studies suggest that group-orientation and social support may buffer or moderate the effects of discrimination (Bierman et al., 2005;

Das-Munshi et al., 2012; Lee, 2005; Seller and Shelton, 2003; Seller et al., 2003). Existing

efforts to counteract discrimination at the community level also allow the opportunity to test whether such efforts have an effect on the incidence of psychotic experiences, which would both support a causal relationship between discrimination and psychosis and provide initial insight on how to use this information to reduce risk.

References

Alegria, M., Vila, D., Woo, M., Canino, G., Takeuchi, D., Vera, M., … Shrout, P., 2004.

Cultural relevance and equivalence in the NLAAS instrument: integrating etic and emic

in the development of cross-cultural measures for a psychiatric epidemiology and

services study of Latinos. International Journal of Methods in Psychiatric Research,

13(4), 270–288.

Anglin, D. M., Greenspoon, M. I., Lighty, Q., Corcoran, C. M., and Yang, L. H., 2013.

Spontaneous labeling and stigma associated with clinical characteristics of peers

‘at‐ risk’for psychosis. Early intervention in psychiatry.

Bécares, L., Nazroo, J., Jackson, J., & Heuvelman, H. (2012). Ethnic density effects on health

and experienced racism among Caribbean people in the US and England: a cross-national

comparison. Social science & medicine, 75(12), 2107-2115.

Bentall, R. P., Corcoran, R., Howard, R., Blackwood, N., & Kinderman, P. (2001). Persecutory

delusions: a review and theoretical integration. Clinical psychology review, 21(8), 1143-

1192.

Bierman, A., 2006. Does religion buffer the effects of discrimination on mental health? Differing

effects by race. Journal for the Scientific Study of Religion, 45(4), 551–565.

Bresnahan, M., Begg, M. D., Brown, A., Schaefer, C., Sohler, N., Insel, B., … Susser, E., 2007.

Race and risk of schizophrenia in a US birth cohort: another example of health disparity?

International Journal of Epidemiology, 36(4), 751–758.

Buckley, P. F., Miller, B. J., Lehrer, D. S., & Castle, D. J. (2009). Psychiatric comorbidities and

schizophrenia. Schizophrenia Bulletin, 35(2), 383-402.

Cantor-Graae, E., & Selten, J. P. (2005). Schizophrenia and migration: a meta-analysis and

review. American Journal of Psychiatry, 162(1), 12-24.

Carter, R. T. (2007). Racism and Psychological and Emotional Injury Recognizing and

Assessing Race-Based Traumatic Stress. The Counseling Psychologist, 35(1), 13-105.

Carter, R. T., & Forsyth, J. (2010). Reactions to racial discrimination: Emotional stress and help-

seeking behaviors. Psychological Trauma: Theory, Research, Practice, and Policy, 2(3),

183.

Cooper, C., Morgan, C., Byrne, M., Dazzan, P., Morgan, K., Hutchinson, G., … Jones, P., 2008.

Perceptions of disadvantage, ethnicity and psychosis. The British Journal of Psychiatry,

192(3), 185–190.

Corcoran, C., Walker, E., Huot, R., Mittal, V., Tessner, K., Kestler, L., and Malaspina, D., 2003.

The stress cascade and schizophrenia: etiology and onset. Schizophrenia Bulletin, 29(4),

671–692.

Das-Munshi, J., Bécares, L., Boydell, J. E., Dewey, M. E., Morgan, C., Stansfeld, S. A., and

Prince, M. J., 2012. Ethnic density as a buffer for psychotic experiences: findings from a

national survey (EMPIRIC). The British Journal of Psychiatry, 201(4), 282–290.

DeVylder, J.E., Oh, H., Corcoran, C., and Lukens, E., 2014. Treatment seeking and unmet need

for care among persons reporting psychosis-like experiences. Psychiatric Services. (in

press).

DeVylder, J. E., Ben-David, S., Schobel, S. A., Kimhy, D., Malaspina, D., and Corcoran, C. M.,

2013b. Temporal association of stress sensitivity and symptoms in individuals at clinical

high risk for psychosis. Psychological Medicine, 43(02), 259–268.

DeVylder, J. E., Oh, H. Y., Yang, L. H., Cabassa, L. J., Chen, F., and Lukens, E. P., 2013a.

Acculturative stress and psychotic-like experiences among Asian and Latino immigrants

to the United States. Schizophrenia Research, 150(1), 223–228.

Dressler, W. W., Oths, K. S., and Gravlee, C. C., 2005. Race and ethnicity in public health

research: models to explain health disparities. Annu. Rev. Anthropol., 34, 231–252.

Fearon, P., Kirkbride, J. B., Morgan, C., Dazzan, P., Morgan, K., Lloyd, T., ... & Murray, R. M.

(2006). Incidence of schizophrenia and other psychoses in ethnic minority groups: results

from the MRC AESOP Study. Psychological medicine, 36(11), 1541-1550.

Fisher, H. L., Caspi, A., Poulton, R., Meier, M. H., Houts, R., Harrington, H., ... and Moffitt, T.

E., 2013. Specificity of childhood psychotic symptoms for predicting schizophrenia by 38

years of age: a birth cohort study. Psychological medicine, 43(10), 2077-2086

Fortuna, L. R., Porche, M. V., and Alegria, M., 2008. Political violence, psychosocial trauma,

and the context of mental health services use among immigrant Latinos in the United

States. Ethnicity and Health, 13(5), 435–463.

Gee, G. C., Spencer, M. S., Chen, J., and Takeuchi, D., 2007. A nationwide study of

discrimination and chronic health conditions among Asian Americans. American Journal

of Public Health, 97(7), 1275–1282.

Gilvarry, C. M., Walsh, E., Samele, C., Hutchinson, G., Mallett, R., Rabe-Hesketh, S., ... &

Murray, R. M. (1999). Life events, ethnicity and perceptions of discrimination in patients

with severe mental illness. Social psychiatry and psychiatric epidemiology, 34(11), 600-

608.

Heeringa, S. G., Wagner, J., Torres, M., Duan, N., Adams, T., and Berglund, P., 2004. Sample

designs and sampling methods for the Collaborative Psychiatric Epidemiology Studies

(CPES). International Journal of Methods in Psychiatric Research, 13(4), 221–240.

Hoffman, R. E. (2007). A social deafferentation hypothesis for induction of active schizophrenia.

Schizophrenia bulletin, 33(5), 1066-1070.

Jackson, J. S., Torres, M., Caldwell, C. H., Neighbors, H. W., Nesse, R. M., Taylor, R. J., …

Williams, D. R., 2004. The National Survey of American Life: a study of racial, ethnic

and cultural influences on mental disorders and mental health. International Journal of

Methods in Psychiatric Research, 13(4), 196–207.

Janssen, I., Hanssen, M., Bak, M., Bijl, R. V., De Graaf, R., Vollebergh, W., … Van Os, J. ,

2003. Discrimination and delusional ideation. The British Journal of Psychiatry, 182(1),

71–76.

Karlsen, S., and Nazroo, J. Y., 2002. Relation between racial discrimination, social class, and

health among ethnic minority groups. American Journal of Public Health, 92(4), 624–

631.

Karlsen, S., Nazroo, J. Y., McKenzie, K., Bhui, K., and Weich, S., 2005. Racism, psychosis and

common mental disorder among ethnic minority groups in England. Psychological

Medicine, 35(12), 1795.

Kaymaz, N., Drukker, M., Lieb, R., Wittchen, H. U., Werbeloff, N., Weiser, M., … Van Os, J.,

2012. Do subthreshold psychotic experiences predict clinical outcomes in unselected

non-help-seeking population-based samples? A systematic review and meta-analysis,

enriched with new results. Psychological Medicine, 42(11), 2239.

Kelly, B. D., O'Callaghan, E., Waddington, J. L., Feeney, L., Browne, S., Scully, P. J., ... &

Larkin, C. (2010). Schizophrenia and the city: A review of literature and prospective

study of psychosis and urbanicity in Ireland. Schizophrenia research, 116(1), 75-89.

Kessler, R. C., Birnbaum, H., Demler, O., Falloon, I. R., Gagnon, E., Guyer, M., … Walters, E.,

2005. The prevalence and correlates of nonaffective psychosis in the National

Comorbidity Survey Replication (NCS-R). Biological Psychiatry, 58(8), 668–676.

Kessler, R. C., Mickelson, K. D., and Williams, D. R., 1999. The prevalence, distribution, and

mental health correlates of perceived discrimination in the United States. Journal of

Health and Social Behavior, 208–230.

Kessler, R. C., and Üstün, T. B., 2004. The world mental health (WMH) survey initiative version

of the world health organization (WHO) composite international diagnostic interview

(CIDI). International Journal of Methods in Psychiatric Research, 13(2), 93–121.

Kilcommons, A. M., & Morrison, A. P. (2005). Relationships between trauma and psychosis: an

exploration of cognitive and dissociative factors. Acta Psychiatrica Scandinavica, 112(5),

351-359.

Krabbendam, L., & Van Os, J. (2005). Schizophrenia and urbanicity: a major environmental

influence—conditional on genetic risk. Schizophrenia bulletin, 31(4), 795-799.

Krieger, N., Smith, K., Naishadham, D., Hartman, C., and Barbeau, E. M., 2005. Experiences of

discrimination: validity and reliability of a self-report measure for population health

research on racism and health. Social Science and Medicine, 61(7), 1576–1596.

Lee, R. M., 2003. Do ethnic identity and other-group orientation protect against discrimination

for Asian Americans? Journal of Counseling Psychology, 50(2), 133.

Morrison, A. P., Frame, L., & Larkin, W. (2003). Relationships between trauma and psychosis: a

review and integration. British Journal of Clinical Psychology, 42(4), 331-353.

Morrison, A. P., & Petersen, T. (2003). Trauma, metacognition and predisposition to

hallucinations in non-patients. Behavioural and Cognitive Psychotherapy, 31(03), 235-

246.

Murphy, J., Shevlin, M., Houston, J., and Adamson, G., 2012. A population based analysis of

subclinical psychosis and help-seeking behavior. Schizophrenia bulletin, 38(2), 360-367.

Myin-Germeys, I., Delespaul, P. H., & Van Os, J. (2005). Behavioural sensitization to daily life

stress in psychosis. Psychological medicine, 35(05), 733-741.

Oh, H., DeVylder, J. E., and Chen, F., 2014. To Treat or Not to Treat: Responding to Psychotic

Experiences. British Journal of Social Work, bct199.

Pascoe, E. A., and Smart Richman, L., 2009. Perceived discrimination and health: a meta-

analytic review. Psychological Bulletin, 135(4), 531.

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(11), 1039-1046.

Pennell, B.-E., Bowers, A., Carr, D., Chardoul, S., Cheung, G., Dinkelmann, K., … Torres, M.,

2004. The development and implementation of the national comorbidity survey

replication, the national survey of American life, and the national Latino and Asian

American survey. International Journal of Methods in Psychiatric Research, 13(4), 241–

269.

Saleem, M. M., Stowkowy, J., Cadenhead, K. S., Cannon, T. D., Cornblatt, B. A., McGlashan, T.

H., … Walker, E. F., 2013. Perceived discrimination in those at clinical high risk for

psychosis. Early Intervention in Psychiatry. Retrieved from

http://onlinelibrary.wiley.com/doi/10.1111/eip.12058/full

Sellers, R. M., Caldwell, C. H., Schmeelk-Cone, K. H., and Zimmerman, M. A., 2003. Racial

identity, racial discrimination, perceived stress, and psychological distress among African

American young adults. Journal of Health and Social Behavior, 302–317.

Sellers, R. M., and Shelton, J. N., 2003. The role of racial identity in perceived racial

discrimination. Journal of Personality and Social Psychology, 84(5), 1079.

Selten, J.-P., and Cantor-Graae, E., 2005. Social defeat: risk factor for schizophrenia? The

British Journal of Psychiatry, 187(2), 101–102.

Selten, J.-P., and Cantor-Graae, E., 2007. Hypothesis: social defeat is a risk factor for

schizophrenia? The British Journal of Psychiatry, 191(51), s9–s12.

Sharpley, M. S., & Peters, E. R. (1999). Ethnicity, class and schizotypy. Social psychiatry and

psychiatric epidemiology, 34(10), 507-512.

Sharpley, M. S., Hutchinson, G., Murray, R. M., and McKenzie, K., 2001. Understanding the

excess of psychosis among the African—Caribbean population in England Review of

current hypotheses. The British Journal of Psychiatry, 178(40), s60–s68.

Sribney, W. M., and Rodríguez, M. A., 2009. Perceived discrimination and self-reported quality

of care among Latinos in the United States. Journal of General Internal Medicine, 24(3),

548–554.

Syed, M., & Juan, M. J. D. (2012). Discrimination and psychological distress: Examining the

moderating role of social context in a nationally representative sample of Asian American

adults. Asian American Journal of Psychology, 3(2), 104-120.

Taylor, T. R., Kamarck, T. W., and Shiffman, S., 2004. Validation of the Detroit Area Study

Discrimination Scale in a community sample of older African American adults: the

Pittsburgh healthy heart project. International Journal of Behavioral Medicine, 11(2), 88–

94.

Thornicroft, G., Brohan, E., Rose, D., Sartorius, N., and Leese, M., 2009. Global pattern of

experienced and anticipated discrimination against people with schizophrenia: a cross-

sectional survey. The Lancet, 373(9661), 408–415.

U.S. Census Bureau. (2010). Urban and rural classification. Retrieved from:

http://www.census.gov/geo/reference/urban-rural.html

U.S. Census Bureau. (2011). Areas with concentrated poverty: 2006-2010. Retrieved from:

www.census.gov/hhes/www/poverty/ van Os, J., Pedersen, C. B., & Mortensen, P. B. (2004). Confirmation of synergy between urbanicity and familial liability in the causation of psychosis. American Journal of Psychiatry,

161(11), 2312-2314.

Van Os, J., Linscott, R. J., Myin-Germeys, I., Delespaul, P., and Krabbendam, L., 2009. A

systematic review and meta-analysis of the psychosis continuum: evidence for a

psychosis proneness-persistence-impairment model of psychotic disorder. Psychological

Medicine, 39(2), 179.

Van Winkel, R., Stefanis, N. C., and Myin-Germeys, I., 2008. Psychosocial stress and psychosis.

A review of the neurobiological mechanisms and the evidence for gene-stress interaction.

Schizophrenia Bulletin, 34(6), 1095–1105.

Van Zelst, C., 2009. Stigmatization as an environmental risk in schizophrenia: a user perspective.

Schizophrenia Bulletin, 35(2), 293–296.

Veling, W., 2013. Ethnic minority position and risk for psychotic disorders. Current Opinion in

Psychiatry, 26(2), 166–171.

Veling, W., Hoek, H. W., and Mackenbach, J. P., 2008. Perceived discrimination and the risk of

schizophrenia in ethnic minorities. Social Psychiatry and Psychiatric Epidemiology,

43(12), 953–959.

Veling, W., Selten, J. P., Veen, N., Laan, W., Blom, J. D., & Hoek, H. W. (2006). Incidence of

schizophrenia among ethnic minorities in the Netherlands: a four-year first-contact study.

Schizophrenia research, 86(1), 189-193.

Veling, W., Selten, J.-P., Susser, E., Laan, W., Mackenbach, J. P., and Hoek, H. W., 2007.

Discrimination and the incidence of psychotic disorders among ethnic minorities in The

Netherlands. International Journal of Epidemiology, 36(4), 761–768.

Wamala, S., Bostrom, G., and Nyqvist, K., 2007. Perceived discrimination and psychological

distress in Sweden. The British Journal of Psychiatry, 190(1), 75–76.

Williams, D. R., Yu, Y., Jackson, J. S., and Anderson, N. B., 1997. Racial differences in physical

and mental health socio-economic status, stress and discrimination. Journal of Health

Psychology, 2(3), 335–351.

Yang, L. H., Anglin, D. M., Wonpat-Borja, A. J., Opler, M. G., Greenspoon, M., and Corcoran,

C. M., 2013. Public stigma associated with psychosis risk syndrome in a college

population: Implications for peer intervention. Psychiatric Services, 64(3), 284-288.

Yang, L. H., Wonpat-Borja, A. J., Opler, M. G., and Corcoran, C. M., 2010. Potential stigma

associated with inclusion of the psychosis risk syndrome in the DSM-V: an empirical

question. Schizophrenia research, 120(1), 42-48.

Chapter III: Major discriminatory events are associated with increased risk for psychotic experiences among Black Americans

Introduction

When compared with White Americans, Black Americans have comparable or lower rates of most major psychiatric disorders, including mood, anxiety, and substance use disorders

(Cogburn, Griffin & Jackson, 2014; Miranda, 2008; Williams & Mohammed, 2009). These findings are paradoxical considering the disadvantaged status of Black Americans and the subsequent exposure to social stressors that increase risk for mental distress and illness in the general population (Keyes, 2009). The prevalence of schizophrenia, however, does not conform to the morbidities of other disorders, and affects Black Americans about two times more than

White Americans (Bresnahan et al., 2007). Socioeconomic status only partially explains this racial disparity, leading researchers to investigate the impact of specific social stressors on psychosis (Tandon et al., 2008), since stress seems to play a key role in the development of schizophrenia and sub-threshold expressions of psychosis (Corcoran et al., 2003).

Racism, discrimination, and social defeat among Black Americans

Given the legacy of racism in the US, discrimination is a common yet complex social determinant of mental health for Black Americans that warrants deeper investigation. The impact of discrimination on health and mental health has been the subject of numerous studies (e.g.

Broman, Mavaddat & Hsu, 2000; Clark et al., 1999; Fisher et al., 2000; Greene et al., 2006;

Kessler et al., 1999; Krieger et al., 2005; Landrine & Klonoff, 1996; Swim et al., 2003; Sellers &

Shelton, 2003; Williams et al., 1997), though researchers have only recently begun to explore the extent to which discrimination impacts risk for psychosis. Existing research in this area draws from social stress theories, casting discrimination as a marker of social disadvantage that

increases exposures to stressors and impedes access to salutary resources (Pearlin & Bierman,

2013). As such, studies have found that social disadvantages increase risk for psychosis (Heinz et al., 2013; Morgan et al., 2008; 2009).

In theory, discrimination contributes to a sense of ‘social defeat’ (Selten and Cantor-

Graae, 2005, 2007), which some researchers have argued elevates the incidence of schizophrenia among ethnic minorities (Sharpley et al., 2001; Fearon et al., 2006; Veling et al., 2006). Indeed, being in a disadvantaged social position has been connected to elevated risk for psychosis, as found among Black ethnic groups in the UK (Cooper et al., 2008; Reininghaus et al., 2010). A person can feel social defeat after being physically or symbolically demeaned, humiliated, and denigrated —despite vain attempts to contest or resist —resulting in a sense of loss or failure

(Luhrmann, 2007). Chronic exposure to aversive experiences (e.g. being subordinated and ostracized) may also sensitize the mesolimbic dopamine system in the brain, which putatively engenders delusions and hallucinations (Howes & Kapur, 2009). For Black Americans, social defeat may become more salient the more the individual becomes aware of the inequality and oppression that is endemic to society (see Harrell, 2011).

Much of the literature examining the effects of discrimination on psychosis has defined discrimination as overtly prejudicial behaviors, perpetrated by individuals who possess irrational ideas or beliefs about a group of people. Discrimination thus becomes purely a social psychological phenomenon examined at the individual level (Bonilla-Silva, 1997). But scholars have argued that racist ideology does not merely influence individual behaviors, it also pervades the very structures of society, preserving the interests of the dominant class. Racism is an entire

“system of power unevenly distributed along racial lines resulting in the oppression and exclusion of non-White groups” (Harrell, 2011, p.144). This system of power not only gives rise

to interpersonal discrimination, but also produces institutional, cultural, and structural forms of discrimination that operate through numerous and complex pathways to impact health (Harrell,

2000; Harrell, 2011; Clark et al., 1999; Krieger 1994; Paradies, 2006). Social conditions are fundamental causes of disease (Link & Phelan 1995; Phelan et al., 2004), and research has yet to analyze how the many facets of racism operate within these social conditions to give rise to psychosis.

Discrimination and psychosis

European population-based studies have found that general discrimination is associated with the increased likelihood of reporting psychotic disorder (Veling et al., 2007; Veling, 2013), with discriminatory verbal abuse increasing the odds of psychotic disorder by two to three fold, and discriminatory physical attacks increasing the odds by three to five fold when compared with those who did not report any experiences of discrimination (Karlsen & Nazroo, 2002; Karlsen et al., 2005). Veling and colleagues (2007) also found that the incidence rate for psychotic disorder was highest among ethnic groups that reported the most severe discrimination at the group level, although this was not true at the individual-level according to a subsequent case–control study

(Veling et al., 2008).

In recent years, researchers have increasingly studied the prevalence and impact of psychosis at the sub-threshold level, which manifests in the general population without creating clinically significant distress or impairment (Johns & van Os, 2001). These psychotic experiences (PE) have been reported in upwards of 7% of the general population (Linscott &

Van Os, 2010). Those who endorse PE seem to feel the need for treatment (Devylder et al., 2013;

Oh et al., 2014), have higher risk of transitioning into full psychotic disorders when compared

with those without PE (Kaymaz et al., 2012; Werbeloff et al., 2012), and also tend to endorse other psychiatric disorders (DeVylder et al., 2014).

Examining the relationship between discrimination and PE is important because such analyses may be able to circumvent issues of reverse causality. Individuals who are diagnosed with psychotic disorders can face tremendous stigma, persecution, and mistreatment (Thornicroft et al., 2009), calling into question whether discrimination is actually a result of psychosis rather than the reverse. Particular symptoms such as paranoia may also bias individuals towards reporting experiences of discrimination. One way to help clarify the causal direction is to examine associations between discrimination and the sub-threshold range of the psychosis continuum, since individuals with PE have not received a formal ‘psychosis’ label nor are they typically in treatment, evading much of the stigma associated with the condition. Only a few studies have examined the association between discrimination and PE.

In Europe, Janssen and colleagues (2003) analyzed data from The Netherlands Mental

Health Survey and Incidence Study (NEMESIS)—a random general population sample of 7076 adult respondents, who were asked (yes/no) if they had ever experienced discrimination on the basis of their skin color/ethnicity, gender, age, appearance, disability, or sexual orientation within the past year. Discrimination was associated with delusional ideation but not hallucinatory experiences, possibly reflecting the effects of discrimination on cognitive attributions of daily events (Gilvarry et al., 1999; Sharpley & Peters, 1999; Bentall et al., 2001). However, interpretation of these findings is limited by the fact that only individuals who were fluent in

Dutch could participate in the survey, thus excluding many racial and ethnic minorities. As such, only a small percentage of their sample endorsed discrimination over the past year, primarily attributing the discrimination to age (6%) and gender (4%), which likely does not correspond to

the systemic, structural, and pervasive racism present in the United States. Their measure did not capture the frequency of discrimination or the types of major discriminatory events over a lifetime. In contrast, my first paper examined samples of racial and ethnic minorities who commonly experienced discrimination, and found that everyday discrimination was also associated with delusional ideation as well as auditory and visual hallucinations in a dose- response relationship.

Major discriminatory events

The aforementioned studies defined their explanatory variable using measures of everyday discrimination (Essed, 1991; Harrell, 2000), which corresponds to the minor events or daily hassles found in the stress literature (e.g. Monroe, 1983; Kanner et al., 1981). Everyday discrimination includes incidents such as being treated with less courtesy and respect, receiving poor service at a restaurant, being threatened and harassed, and being regarded as unintelligent, dangerous, dishonest, and unworthy. These events tend to occur repeatedly and frequently throughout a person’s life (i.e. chronic) and tend to have an immediate impact on a person’s thoughts, feelings, and actions (Lazarus & Folkman, 1984, p.231). However, everyday discrimination is primarily used to make inferences at the individual level without accounting for the fact that discrimination is grounded in the unequal foundations of society.

As a conceptually distinct phenomenon, major discriminatory events correspond to what the stress literature refers to as major life events (Dohrenwend et al., 1978; Kanner et al., 1981), which are more severe or distressing incidents that occur less frequently than minor events or daily hassles. Major life events may have a different impact on mental health (Kessler et al.,

1999), possibly because the nature of the events can be distal (Wagner et al., 1988). Examples

include being unfairly fired, abused by the police, prevented from moving into a neighborhood, among others (see Table 1). When compared with everyday discrimination, these major events may serve as better proxies for structural discrimination because they implicate entire establishments, communities, and institutions. Experiencing these events raises awareness of one’s earning power and rewards in the labor market, one’s value as a consumer in the service sector, one’s relationship to the police state, one’s chances of residing in a validating or hostile neighborhood, one’s access to financial, educational, and social institutions. And so while measures of everyday discrimination capture how racist ideology is expressed in interpersonal encounters, major discriminatory events elucidate, at least in part, how racist ideology is embedded in the values, practices, and arrangements that perpetuate the power and privilege of the dominant class (Bonilla-Silva 1997, 2001, 2006).

To my knowledge, only one study has examined the effect of major discriminatory events on PE. Anglin and colleagues (2014) analyzed a sample of 650 young adults in an urban context who were predominantly immigrant or racial/ethnic minorities, and found that discrimination was associated with increased odds of endorsing cognitive disorganization, unusual thinking, perceptual abnormalities, and paranoia. The authors used a measure of discrimination that asked respondents whether they had been hindered, hassled, or devalued because of their race, ethnicity, or color in various situations, including: seeking employment, working, seeking housing, seeking medical care, getting service in a store, getting credit or a bank loan, on the street or in a public setting or at school, from the police or in the courts (Krieger, 2005). The effects were likely underestimated due to fact that the sample was restricted to adults aged 18-27 years old, who may not have had a chance to experience being denied a loan, not getting housing, and so forth. Moreover, the highest endorsement in this sample was discrimination that

occurred on the street or in a public setting, which more closely aligns with the concept of everyday discrimination.

Still, Anglin’s study exemplifies the reality that major discriminatory events occur in various domains of life. However, no theory exists to explain why specific kinds of discriminatory events would have certain effects on psychotic experiences. Using a predominantly white sample, Kessler and colleagues (1999) disaggregated the major discrimination into individual events, and found that employment related discrimination (e.g. being fired or not being hired) predicted psychological distress, while not being hired, being hassled by police, and being denied a bank loan predicted major depression. Their analyses were largely exploratory and showed that different events did in fact have different effects on mental health, but they did not offer a framework to guide future studies. Further, their analyses have yet to be replicated using PE as the main outcome of interest, or using samples of Black Americans in the general population.

Aims and Hypotheses

Using the National Survey of American Life (NSAL; Jackson et al., 2004), I examined the associations between major discriminatory events and PE among a sample of Black

Americans. I hypothesized that (a) endorsement of major discriminatory events across multiple domains would be associated with increased probability of reporting lifetime PE; and (b) major discriminatory events would be associated with all experiences, including hallucinatory experiences and delusional ideation.

Methods

Sample and procedures

This paper analyzed data from the National Survey of American Life (NSAL) (Jackson et al., 2004), a national household probability sample of 5191 Black Americans (3570 African

Americans and 1621 Caribbean Black Americans) that was conducted between the years 2001 and 2003 using the World Health Organization Composite International Diagnostic Interview

(WHO CIDI; Kessler and Üstün, 2004). The study population included non-institutionalized adults over the age of 18 who were selected through a multistage probability sampling strategy to achieve nationally representative samples of African Americans living in the United States

(Heeringa et al., 2004). Special supplements were used to oversample from census block groups with high-density of individuals of Caribbean national origin (Heeringa et al., 2004). Non-

Hispanic whites in the NSAL (n=891) were omitted from this analysis because they did not complete the psychosis screen. The response rate for the overall NSAL sample was 72.3%

(70.7% for African American and 77.7% for the Caribbean Blacks). Details on the sampling strategy and interview procedures have been described in depth elsewhere (see Pennell et al.,

2004). The survey investigators provided survey weighting (NSALWTCT) and stratification

(SESTRAT) variables.

Of the 5191 respondents, 197 were dropped because they did not complete the psychosis screen. Out of the remaining 4994 respondents, 450 respondents did not complete all nine discrimination items; respondents who answered ‘not applicable’ or ‘don’t know’ on any of the discrimination items were dropped. Individuals with missing values on other demographic variables of interest were also dropped (n=5), resulting in a total analytic sample of 4539

respondents, 3134 of which were African–American (93.17%, weighted), and 1405 of which were Afro-Caribbean American (6.83%, weighted).

Measures

WHO-CIDI 3.0 Psychosis Screen

Respondents were asked to report the lifetime presence of six specific PE from the WHO-

CIDI 3.0 psychosis screen, including: (1) visual hallucinations, (2) auditory hallucinations, (3) thought insertion, (4) thought control, (5) telepathy, (6) delusions of persecution. Responses were not considered a PE if the experience took place in the context of falling asleep, dreaming, or substance use. Thought insertion, thought control, telepathy, and delusions of persecution constituted the delusion subtype. Endorsing at least one of these experiences during one’s lifetime constituted a positive endorsement of lifetime PE.

Given the poor retest consistency between earlier CIDI diagnostic field interviews and clinical follow-up diagnostic interviews for psychotic disorder (Kendler et al., 1996), the WHO-

CIDI 3.0 psychosis screen did not use a diagnostic module for full psychotic disorder and therefore only captured sub-clinical psychosis. The WHO-CIDI psychosis screen is a common measure of PE and has been validated through associations with hospital admissions and the development of full psychotic disorder in a dose–response fashion (Kaymaz et al., 2012).

Major Discrimination

Discrimination was assessed using a questionnaire adapted from the Lifetime

Discrimination sub scale of the Detroit Area Study Discrimination Questionnaire (DAS-DQ;

Taylor, Kamarck, & Shiffman, 2004), and had a Cronbach’s alpha of 0.64. Respondents

indicated whether or not they had ever experienced nine specific major discriminatory events in their lifetimes (Table 2). Due to the skewed distribution of the data, I created a variable that counted how many of the nine discriminatory events were endorsed by the respondent, and I discretized this count variable into three categories, representing 0, 1-2, and 3+ discriminatory events, consistent with prior studies (e.g. Chae et al., 2012). About 38.32% of the weighted sample reported no discriminatory events, 40.66% reported one or two types of events, and

20.91% reported three or more types of events.

I decided to analyze general discrimination and not solely racial discrimination for a couple of reasons. First, respondents were given the option to choose one aspect of their identities that made them subject to each of the discriminatory events. While the majority of respondents believed they were discriminated against based on their race/ethnicity, some believed they were discriminated against on the basis of their gender, sexual orientation, religion, and other reasons. The attribution categories were mutually exclusive and did not allow for the possibility of intersectionality (Crenshaw, 1991; Cole, 2009; Collins, 2000), which posits that people are oppressed according to their multiple social identities. For instance, a person can be discriminated against on the basis of both race and gender, which taken together confer a unique burden on the individual; however, the discrimination measure in my study would not allow for this kind of intersectionality, prompting me to use general discrimination.

Second, discrimination is primarily measured through subjective self-report, and I argue that discrimination can be racist even though the person experiencing it does not acknowledge the event as such. While attributions may play an important role at the inter-personal level, I argue that because structural racism is subtle, covert, and implicit (Boniila-Silva, 1997), attributions may be less relevant for my analyses. Take for instance the fact that neighborhood-

related discrimination (e.g. home mortgage lending practices, redlining, blockbusting, racial steering) is not always detectable and yet has long-term and indirect effects on health by way of residential segregation and subsequent deprivations of resources (e.g. barriers to quality schools and employment opportunities) and exposures to environmental stressors. Thus I chose to focus on general discrimination given the distal nature of major discriminatory events.

Covariates

Demographic covariates included ethnicity, age, sex, marital status, and education level, all of which were self-reported by participants as part of the WHO-CIDI battery. Clinical diagnoses of interest included substance use (alcohol abuse, alcohol dependence, drug abuse, or drug dependence) and post-traumatic stress disorder (PTSD) because these variables are often associated with discrimination and ethnic minority status. Urbanicity is a risk factor for psychosis that is also associated with discrimination, and so I controlled for both region

(Northeast, Midwest, South, West) and income-to-poverty ratio, which tend to correlate with urbanicity. Also, because of the social deafferentation hypothesis (Hoffman, 2007) that states symptoms arise from loss of social contact, I also controlled for social interaction using the

WHO Disability Assessment Schedule, which is a reliable instrument to assess health and disability in the general population (Ustun, 2010; Chopra et al., 2004).

Analyses

I performed all analyses using STATA SE version 13, and conducted primary analyses using completed cases. I first used simple bi-variable logistic regression to examine the individual effects of each major discriminatory event on PE. While exposure to discriminatory

events may contribute stress that increases risk for PE, persecutory delusions can also make a person inclined to mistakenly interpret events as discrimination. This reverse causality problem is less evident with respect to hallucinations. And so I analyzed PE subtypes (visual, auditory, delusional) to show that the effect of discrimination on PE is not purely driven by delusions.

After running bi-variable models between each event and PE, I ran multivariable logistic regression models adjusting for demographic variables, socioeconomic status, and co-occurring psycho-social problems. I then ran adjusted models using a count of major discriminatory events.

I reported effect sizes as odds ratios (OR), and given the size of my sample and the number of tests I ran, I set the alpha at a more conservative level of 0.01, and defined p-values less than alpha=0.05 as marginally significant.

Missing Data

Missing data became problematic when using the discrimination measure, since individuals who reported ‘not applicable’ and ‘I don’t know’ on any one of the nine items were dropped from the analyses. To verify my findings, I ran additional sensitivity analyses. First I ran models for each discriminatory event without restricting the sample to completed cases, allowing each discriminatory event its own subsample independent of how the respondents answered the other items of major discrimination. This retained much of the sample, though the sample size varied across models. Second, instead of dropping respondents who reported ‘I don’t know’ and

‘Not applicable’, I conflated these responses with the ‘No’ category, effectively creating a dichotomous variable that captured ‘Yes’ versus ‘Not Yes’, which further preserved the analytic sample. Findings from these sensitivity analyses did not vary substantially from my original analyses.

Results

The average number of discriminatory events for the total analytic sample was 1.43 events. About 11.83% of the analytic sample reported lifetime PE, 8.99% reported a lifetime visual hallucination, 5.07% reported a lifetime auditory hallucination, and 1.9% reported a lifetime delusional ideation. There were no significant differences between African Americans and Black Caribbean Americans on any of these variables, except that African Americans were somewhat more likely to report auditory hallucinations (Table 3). Police abuse was the most common form of discrimination, followed by employment-related discrimination.

Neighborhood-related discriminatory events were the least common.

Table 1. Descriptive statistics of major discriminatory events and psychotic experiences using completed cases (N=4539)

Lifetime PE

Total* PE* No PE* F-statistic

Unfairly fired 24.43 (0.84) 32.02 (3.33) .2342 (0.96) 6.22

Not hired 22.11 (1.01) 26.29 (2.49) 21.55 (1.09) 3.43

Denied promotion 19.89 (1.03) 24.71 (2.45) 19.25 (1.05) 5.82

Police abuse 27.02 (1.26) 38.51 (2.87) 25.47 (1.31) 20.27

Discouraged from 10.36 (0.78) 16.85 (2.74) 9.49 (0.76) 10.56 education

Neighborhood 8.62 (0.74) 13.63 (2.21) 7.95 (0.63) 14.53 exlcusion

Neighbor harassment 7.60 (0.54) 13.59 (2.20) 6.80 (0.50) 16.24

Denied loan 10.10 (0.63) 18.06 (2.00) 9.03 (0.70) 23.45

Bad service 12.88 (0.88) 22.14 (3.30) 11.63 (0.82) 14.79

*Weighted percentages (standard errors)

Table 2. Descriptive statistics of major discriminatory events and subtypes of PE using completed cases (N=4539)

Visual Auditory Delusional

Visual* No F-statistic Auditory* No F-statistic Delusion* No F-statistic Visual* Auditory* Delusion*

Unfairly 31.70 23.72 31.83 24.04 33.26 24.26 5.55 0.10 1.43 fired (3.33) (0.93) (0.05) (0.01) (8.25) (0.82)

Not hired 25.86 21.74 25.79 21.91 35.18 21.85 2.08 1.24 2.87 (2.78) (1.08) (3.50) (1.05) (8.95) (0.99)

Denied 24.00 19.49 26.97 19.52 20.23 19.89 3.18 4.05 0.00 promotion (2.72) (1.05) (4.21) (1.02) (5.75) (1.02)

Police 38.69 25.86 34.97 26.59 44.08 26.68 12.22 4.02 9.23 abuse (3.75) (1.30) (4.20) (1.30) (6.66) (1.21)

Discourage 17.55 9.65 13.46 10.20 24.12 10.09 d from 13.36 1.21 8.20 education (2.69) (0.76) (3.63) (0.71) (6.59) (0.78)

Neighborh 11.99 8.28 14.31 8.31 21.02 8.38 ood 4.14 4.80 7.83 (2.31) (0.70) (3.60) (0.70) (6.59) (0.71) exclusion

Neighbor 14.00 6.97 9.57 21.51 7.34 14.59 7.5 (0.54) 0.66 8.01 harassment (2.51) (0.49) (2.82) (7.43) (0.50)

Denied 17.63 9.35 21.66 9.48 14.38 10.01 16.79 15.24 0.75 loan (2.24) (0.67) (3.52) (0.73) (5.44) (0.68)

Bad 21.13 12.06 24.21 12.27 21.72 12.71 10.76 12.71 3.75 service (3.36) (0.85) (4.04) (0.87) (5.59) (0.88)

*Weighted percentages (standard error)

Table 3. Descriptive statistics of range of discriminatory events and psychotic experience subtypes by ethnicity using completed cases (N=4539)

Total Sample* African American* Black Caribbean F-Statistic (p-value) American*

Range of Major Discriminatory Events

0 38.32 (1.18) 38.54 (1.25) 35.31 (2.97) 0.98 (0.32)

1-2 types of 40.66 (0.86) 40.81 (0.89) 40.23 (3.64) 0.02 (0.88) events

3 or more 20.91 (0.98) 20.64 (1.02) 24.46 (3.75) 1.06 (0.30) types of events

Psychotic Experiences

Lifetime 11.83 (0.84) 11.95 (0.90) 10.09 (0.97) 1.91 (0.17)

Subtypes

Visual 8.99 (0.67) 8.97 (0.71) 9.2 (1.00) 0.04 (0.85)

Auditory 5.07 (0.56) 5.25 (0.60) 2.6 (0.75) 5.27 (0.03)

Delusional 1.9 (0.33) 1.85 (0.34) 2.63 (1.05) 0.65 (0.42)

*Weighted percentages (standard errors)

Bi-variable logistic regression models showed that all events were associated with increased risk for lifetime PE except employment-related discrimination. After adjusting for covariates (demographic variables, socioeconomic status, co-occurring psycho-social problems), police abuse, being denied a loan, and receiving unusually bad service remained significant. The effect sizes for discriminatory events attenuated, except for police abuse, which consistently increased risk for lifetime PE by 83% before and after adjustment (Table 4).

In terms of PE subtypes, I found that police abuse, being denied a loan, and receiving unusually bad service were associated with increased risk for lifetime visual hallucinatory experiences after controlling for covariates. Police abuse remained unaffected by adjustments,

while effects for all other discriminatory events diminished. Being denied a loan was associated with increased risk for auditory hallucinatory experiences, and none of the events were associated with increased risk for delusional ideation after controlling for covariates (Table 5).

Multivariable logistic regression analyses showed that when compared with individuals who did not report lifetime discrimination, those who reported one or two kinds of discriminatory events were almost twice as likely to report lifetime PE, and those who reported three or more were almost two and a half times more likely, adjusting for demographic variables, socioeconomic status, co-occurring psycho-social problems. I found similar dose-response effects across all PE subtypes, though effects were only significant for visual hallucinations at the a=0.01 level (Table 6).

Table 4. Bi-variable and adjusted logistic regression models depicting the impact of each major discriminatory event on lifetime and 12-month psychotic experiences using completed cases (N=4539)

Bi-variable Lifetime PE Adjusted Lifetime PE OR (95% CI) OR (95% CI)

Unfairly fired 1.54 (1.09-2.18)* 1.18 (0.82-1.70)

Not hired 1.30 (0.97-1.72) 1.12 (0.85-1.46)

Denied promotion 1.38 (1.06-1.80)* 1.29 (1.02-1.64)*

Police abuse 1.83 (1.40-2.40)*** 1.83 (1.37-2.45)***

Discouraged from education 1.93 (1.29-2.90)*** 1.56 (1.01-2.43)*

Excluded from neighborhood 1.83 (1.33-2.51)*** 1.51 (1.05-2.16)*

Neighbor harassment 2.15 (1.47-3.16)*** 1.68 (1.10-2.58)*

Denied loan 2.22 (1.60-3.09)*** 2.06 (1.44-2.94)***

Bad service 2.16 (1.45-3.23)*** 1.90 (1.32-2.74)**

Adjusted for ethnicity, gender, age, marital status, education, employment status, income-to-poverty ratio, region of country, lifetime substance use, lifetime ptsd, social isolation *p<0.05; **p<0.01; ***p<001

Table 5. Bi-variable and adjusted logistic regression models depicting the impact of each major discriminatory event on subtypes of psychotic experiences using completed cases (N=4539)

Visual Auditory Delusion OR (95% CI) OR (95% CI) OR (95% CI)

Bi-variable Adjusted Bi-variable Adjusted Bi-variable Adjusted Lifetime Visual Lifetime Visual Lifetime Lifetime Lifetime Lifetime Auditory Auditory Delusion Delusion

Unfairly fired 1.49 (1.06- 1.21 (0.82- 1.48 (0.92- 1.02 (0.62- 0.94 (0.44-2.01) 1.56 (0.74-3.26) 2.10)* 1.79) 2.36) 1.67)

Not hired 1.26 (0.91- 1.12 (0.84- 1.24 (0.84- 0.99 (0.66- 1.45 (0.66-3.16) 1.94 (0.89-4.25) 1.73) 1.52) 1.82) 1.50)

Denied 1.25 (0.95- 1.52 (1.00- 1.25 (0.83- 0.81 (0.34-1.93) 1.3 (0.96-1.76) 1.02 (0.51-2.04) promotion 1.65) 2.32) 1.88)

Police abuse 1.81 (1.29- 2.09 (1.46- 1.48 (1.00- 1.14 (0.73- 2.16 (1.30- 1.25 (0.69-2.26) 2.54)*** 2.99)*** 2.20) 1.81) 3.61)***

Discouraged 1.99 (1.37- 1.64 (1.10- 1.37 (0.77- 1.00 (0.53- 2.83 (1.37- 2.2 (1.07-4.51)* from education 2.91)*** 2.46)* 2.43) 1.90) 5.87)*

Excluded from 1.51 (1.01- 1.19 (0.76- 1.84 (1.05- 1.46 (0.88- 2.91 (1.35- 2.19 (0.93-5.16) neighborhood 2.26) 1.89) 3.22)* 2.44) 6.26)*

Neighbor 2.17 (1.45- 1.65 (1.01- 1.30 (0.68- 0.93 (0.43- 3.46 (1.43- 2.3 (0.81-6.50) harassment 3.26)*** 2.67)* 2.51) 2.04) 8.34)*

Denied loan 2.07 (1.45- 1.85 (1.27- 2.64 (1.60- 2.25 (1.34- 1.48 (0.61-3.56) 1.51 (0.58-3.92) 2.96)*** 2.69)** 4.34)*** 3.78)**

Bad service 1.95 (1.30- 1.72 (1.21- 2.28 (1.44- 1.84 (1.12- 1.46 (0.62-3.47) 1.91 (0.98-3.72) 2.94)** 2.45)** 3.63)*** 3.04)*

Table 6. Adjusted logistic regression models depicting the associations between range of general discrimination and PE using completed cases (n=4539)

Lifetime Visual Auditory Delusion OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Discrimination

None (0) 1.00 1.00 1.00 1.00

1-2 types of 1.94 (1.39-2.70)*** 1.70 (1.28-2.26)*** 2.02 (1.18-3.47)* 3.16 (1.29-7.79)* events

3 or more 2.40 (1.64-3.52)*** 2.03 (1.40-2.97)*** 1.94 (1.09-3.48)* 3.50 (1.41-8.70)* types of events

Discussion

My main findings showed that experiencing a broader range of major discriminatory events is associated with an increased risk of endorsing lifetime PE in a dose-response fashion.

As a count of events, discrimination yielded a significant and strong effect; however, after disaggregating the discriminatory events to look at individual effects, certain major discriminatory events –namely being abused by the police, being denied a bank loan, and receiving unusually bad service –contributed more significant and pronounced effects. Police abuse was unique in that its effects did not attenuate after adjusting for covariates. While no guiding framework exists to organize the relationships between discriminatory events and psychotic experiences, conceivably the strength of association may depend on the discriminatory event’s likelihood of proliferating everyday stressors (Kanner et al., 1981), changing the subjective meaning of daily stressors (Pearlin et al., 1981), impacting the emotional reactivity to daily stressors (Myin-Germeys, 2003), or having more enduring or life-altering implications.

I acknowledge that discrimination and psychotic experiences can be difficult to disentangle from each other when using survey measures. Take for instance the item: “Did you

ever believe that there was an unjust plot going on to harm you or to have people follow you that your family and friends did not believe was true?” This item intends to capture paranoia in the psychosis scale, but may also reflect characteristics of discrimination as well, depending on how the respondent interprets the question. Further, a person who has a persecutory delusional ideation —that is, the false and fixed beliefs of being harassed, attacked, or stymied –might mistakenly interpret any kind of stressful event as discrimination, thus creating the possibility of reverse causality. In other words, delusional ideation may make people prone to see illusory machinations all around them, including the events described on the discrimination measure. I did in fact observe strong (but insignificant) associations between discrimination and delusional ideation; however, I also observed associations between discrimination and hallucinatory experiences, suggesting that the effect of discrimination on PE was not mainly attributable to delusional ideation.

One institution that was not implicated in the discrimination measure but still plays a role in my findings is the institution of psychiatry, which has over the years perpetrated racism by systematically over-diagnosing Black Americans with psychosis (Minsky et al., 2003). Jonathan

Metzl (2009) notes that throughout the latter half of the 20th century, the criteria for psychosis were racially-biased and clinicians were primed to see Black men fighting for civil rights as volatile, aggressive, and therefore psychotic. Thus, the diagnostic criteria for schizophrenia became a politicized ethno-racial artifact. Many of the pathologized behaviors of Black

Americans may actually be what Grier & Cobbs (1968) referred to as cultural paranoia –that is, the suspicion or apprehension that Black Americans feel toward their White psychiatric providers (Ridley, 1984), which is an adaptive response to racism and oppression (Whaley,

2001).

Indeed the measure of discrimination may have captured delusional ideation in addition to adaptive responses to discrimination and other cultural misunderstandings. But what is also true based on psychiatric epidemiology literature is that Black Americans do in fact inhabit environments where social forces seem to conspire against them. Black Americans experience discrimination regularly, which causes stress and even trauma (Bryant-Davis & Ocampo, 2005;

Carter, 2007; Waelde et al., 2010), increasing the chances of developing psychosis. My findings suggest that the threat of racism can be traced back to foundations of society, the very institutions and structures that form the material basis for discrimination —effectively restricting

Black Americans from salutary resources, while conferring stress that accumulates over the life course. Thus, researchers should continue to unpack racism as a multidimensional construct, examining the unique effects of different forms and facets of racism on various psychotic states – from sub-threshold experiences to full disorders –and how lifetime adversities tied to racism can influence treatment success and recovery from and in psychosis (see Hassan & De Luca, 2014).

My findings have critical implications for training and sensitizing health and mental health professionals, calling attention to the risk factors for psychosis, and calling for implementation and monitoring of programs to care for those individuals and communities affected. My findings should also stimulate conversations amongst professionals outside of the field of mental health, particularly amongst law enforcement, given the notable relationship between police discrimination and PE. This can motivate trainings to help police officers become aware of their unconscious biases while appreciating the impact of their actions.

References

Anglin, D. M., Lighty, Q., Greenspoon, M., & Ellman, L. M. (2014). Racial discrimination is

associated with distressing subthreshold positive psychotic symptoms among US urban

ethnic minority young adults. Social Psychiatry and Psychiatric Epidemiology, 1–11.

Bentall, R. P., Corcoran, R., Howard, R., Blackwood, N., & Kinderman, P. (2001). Persecutory

delusions: a review and theoretical integration. Clinical Psychology Review, 21(8), 1143–

1192.

Bonilla-Silva, E. (1997). Rethinking racism: Toward a structural interpretation. American

Sociological Review, 465–480.

Bonilla-Silva, E. (2001). White supremacy and racism in the post-civil rights era. Lynne Rienner

Publishers. Retrieved from

http://books.google.com/books?hl=en&lr=&id=rVcdyCYwnosC&oi=fnd&pg=PR7&dq=

bonilla-silva+2001&ots=R_ceMo2Vbd&sig=GfZsxe7KaE3v0Tvx0ZQAh5nhFMU

Bonilla-Silva, E. (2006). Racism without racists: Color-blind racism and the persistence of

racial inequality in the United States. Rowman & Littlefield Publishers. Retrieved from

http://books.google.com/books?hl=en&lr=&id=HKJE4rVZG1EC&oi=fnd&pg=PR7&dq

=bonilla-silva+2006&ots=lcB_wOK1W6&sig=xcda2gMLGSaJGrnfig3aBerun08

Bresnahan, M., Begg, M. D., Brown, A., Schaefer, C., Sohler, N., Insel, B., … Susser, E. (2007).

Race and risk of schizophrenia in a US birth cohort: another example of health disparity?

International Journal of Epidemiology, 36(4), 751–758.

Broman, C. L., Mavaddat, R., & Hsu, S.-Y. (2000). The experience and consequences of

perceived racial discrimination: A study of African Americans. Journal of Black

Psychology, 26(2), 165–180.

Bryant-Davis, T., & Ocampo, C. (2005). Racist incident–based trauma. The Counseling

Psychologist, 33(4), 479–500.

Carter, R. T. (2007). Racism and Psychological and Emotional Injury Recognizing and

Assessing Race-Based Traumatic Stress. The Counseling Psychologist, 35(1), 13–105.

Chae, D. H., Nuru-Jeter, A. M., Lincoln, K. D., & Jacob Arriola, K. R. (2012). Racial

discrimination, mood disorders, and cardiovascular disease among Black Americans.

Annals of Epidemiology, 22(2), 104–111.

Chopra, P. K., Couper, J. W., & Herrman, H. (2004). The assessment of patients with long-term

psychotic disorders: application of the WHO Disability Assessment Schedule II.

Australian and New Zealand Journal of Psychiatry, 38(9), 753–759.

Clark, R., Anderson, N. B., Clark, V. R., & Williams, D. R. (1999). Racism as a stressor for

African Americans: A biopsychosocial model. American Psychologist, 54(10), 805.

Cobbs, P. M., & Grier, W. H. (1968). Black rage. New York: Basic Books.

Cole, E. R. (2009). Intersectionality and research in psychology. American Psychologist, 64(3),

170.

Collins, P. H. (2000). Gender, black feminism, and black political economy. The Annals of the

American Academy of Political and Social Science, 568(1), 41–53.

Cooper, C., Morgan, C., Byrne, M., Dazzan, P., Morgan, K., Hutchinson, G., … others. (2008).

Perceptions of disadvantage, ethnicity and psychosis. The British Journal of Psychiatry,

192(3), 185–190.

Corcoran, C., Walker, E., Huot, R., Mittal, V., Tessner, K., Kestler, L., & Malaspina, D. (2003).

The stress cascade and schizophrenia: etiology and onset. Schizophrenia Bulletin, 29(4),

671–692.

Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and violence

against women of color. Stanford Law Review, 1241–1299.

DeVylder, J. E., Burnette, D., & Yang, L. H. (n.d.). Co-occurrence of psychotic experiences and

common mental health conditions across four racially and ethnically diverse population

samples. Psychological Medicine, 1–11.

DeVylder, J. E., Oh, H. Y., Corcoran, C. M., & Lukens, E. P. (2014). Treatment Seeking and

Unmet Need for Care Among Persons Reporting Psychosis-Like Experiences.

Psychiatric Services. Retrieved from

http://journals.psychiatryonline.org/article.aspx?articleid=1832054

Dohrenwend, B. S., Askenasy, A. R., Krasnoff, L., & Dohrenwend, B. P. (1978).

Exemplification of a method for scaling life events: The PERI Life Events Scale. Journal

of Health and Social Behavior, 205–229.

Essed, P. (1991). Understanding everyday racism: An interdisciplinary theory (Vol. 2). Sage.

Retrieved from

http://books.google.com/books?hl=en&lr=&id=gIpjszJFqWQC&oi=fnd&pg=PR6&dq=e

ssed+1991&ots=-GdHCiPkac&sig=3cDEGEIOUCn_IagxTxFiUn8SJgw

Fearon, P., Kirkbride, J. B., Morgan, C., Dazzan, P., Morgan, K., Lloyd, T., … others. (2006).

Incidence of schizophrenia and other psychoses in ethnic minority groups: results from

the MRC AESOP Study. Psychological Medicine, 36(11), 1541–1550.

Fisher, C. B., Wallace, S. A., & Fenton, R. E. (2000). Discrimination distress during

adolescence. Journal of Youth and Adolescence, 29(6), 679–695.

Gilvarry, C. M., Walsh, E., Samele, C., Hutchinson, G., Mallett, R., Rabe-Hesketh, S., …

Murray, R. M. (1999). Life events, ethnicity and perceptions of discrimination in patients

with severe mental illness. Social Psychiatry and Psychiatric Epidemiology, 34(11), 600–

608.

Greene, M. L., Way, N., & Pahl, K. (2006). Trajectories of perceived adult and peer

discrimination among Black, Latino, and Asian American adolescents: patterns and

psychological correlates. Developmental Psychology, 42(2), 218.

Harrell, C. J. P., Burford, T. I., Cage, B. N., Nelson, T. M., Shearon, S., Thompson, A., & Green,

S. (2011). Multiple pathways linking racism to health outcomes. Du Bois Review: Social

Science Research on Race, 8(01), 143–157.

Harrell, S. P. (2000). A multidimensional conceptualization of racism-related stress: implications

for the well-being of people of color. American Journal of Orthopsychiatry. Retrieved

from http://psycnet.apa.org/psycinfo/2000-13882-005

Hassan, A. N., & De Luca, V. (2014). The effect of lifetime adversities on resistance to

antipsychotic treatment in schizophrenia patients. Schizophrenia Research. Retrieved

from http://www.sciencedirect.com/science/article/pii/S0920996414006458

Heeringa, S. G., Wagner, J., Torres, M., Duan, N., Adams, T., & Berglund, P. (2004). Sample

designs and sampling methods for the Collaborative Psychiatric Epidemiology Studies

(CPES). International Journal of Methods in Psychiatric Research, 13(4), 221–240.

Heinz, A., Deserno, L., & Reininghaus, U. (2013). Urbanicity, social adversity and psychosis.

World Psychiatry, 12(3), 187–197.

Howes, O. D., & Kapur, S. (2009). The dopamine hypothesis of schizophrenia: version III—the

final common pathway. Schizophrenia Bulletin, 35(3), 549–562.

Hoffman, R. E. (2007). A social deafferentation hypothesis for induction of active schizophrenia.

Schizophrenia bulletin, 33(5), 1066-1070.

Jackson, J. S., Torres, M., Caldwell, C. H., Neighbors, H. W., Nesse, R. M., Taylor, R. J., …

Williams, D. R. (2004). The National Survey of American Life: a study of racial, ethnic

and cultural influences on mental disorders and mental health. International Journal of

Methods in Psychiatric Research, 13(4), 196–207.

Janssen, I., Hanssen, M., Bak, M., Bijl, R. V., De Graaf, R., Vollebergh, W., … Van Os, J.

(2003). Discrimination and delusional ideation. The British Journal of Psychiatry, 182(1),

71–76.

Johns, L. C., & van Os, J. (2001). The continuity of psychotic experiences in the general

population. Clinical Psychology Review, 21(8), 1125–1141.

Kanner, A. D., Coyne, J. C., Schaefer, C., & Lazarus, R. S. (1981). Comparison of two modes of

stress measurement: Daily hassles and uplifts versus major life events. Journal of

Behavioral Medicine, 4(1), 1–39.

Karlsen, S., & Nazroo, J. Y. (2002). Relation between racial discrimination, social class, and

health among ethnic minority groups. American Journal of Public Health, 92(4), 624–

631.

Karlsen, S., Nazroo, J. Y., McKenzie, K., Bhui, K., & Weich, S. (2005). Racism, psychosis and

common mental disorder among ethnic minority groups in England. Psychological

Medicine, 35(12), 1795–1803.

Kaymaz, N., Drukker, M., Lieb, R., Wittchen, H.-U., Werbeloff, N., Weiser, M., … van Os, J.

(2012). Do subthreshold psychotic experiences predict clinical outcomes in unselected

non-help-seeking population-based samples? A systematic review and meta-analysis,

enriched with new results. Psychological Medicine, 42(11), 2239–2253.

Kendler, K. S., Gallagher, T. J., Abelson, J. M., & Kessler, R. C. (1996). Lifetime prevalence,

demographic risk factors, and diagnostic validity of nonaffective psychosis as assessed in

a US community sample: the National Comorbidity Survey. Archives of General

Psychiatry, 53(11), 1022–1031.

Kessler, R. C., Mickelson, K. D., & Williams, D. R. (1999). The prevalence, distribution, and

mental health correlates of perceived discrimination in the United States. Journal of

Health and Social Behavior, 208–230.

Kessler, R. C., & Üstün, T. B. (2004). The world mental health (WMH) survey initiative version

of the world health organization (WHO) composite international diagnostic interview

(CIDI). International Journal of Methods in Psychiatric Research, 13(2), 93–121.

Keyes, C. L. (2009). The Black–White paradox in health: Flourishing in the face of social

inequality and discrimination. Journal of Personality, 77(6), 1677–1706.

Krieger, N., Chen, J. T., Waterman, P. D., Rehkopf, D. H., & Subramanian, S. V. (2005).

Painting a truer picture of US socioeconomic and racial/ethnic health inequalities: the

Public Health Disparities Geocoding Project. American Journal of Public Health, 95(2),

312–323.

Krieger, N., Smith, K., Naishadham, D., Hartman, C., & Barbeau, E. M. (2005). Experiences of

discrimination: validity and reliability of a self-report measure for population health

research on racism and health. Social Science & Medicine, 61(7), 1576–1596.

Landrine, H., & Klonoff, E. A. (1996). The schedule of racist events: A measure of racial

discrimination and a study of its negative physical and mental health consequences.

Journal of Black Psychology, 22(2), 144–168.

Lazarus, R. S., & Folkman, S. (1984). Stress. Appraisal, and Coping, 456.

Link, B. G., & Phelan, J. (1995). Social conditions as fundamental causes of disease. Journal of

Health and Social Behavior, 80–94.

Linscott, R. J., & Van Os, J. (2010). Systematic reviews of categorical versus continuum models

in psychosis: evidence for discontinuous subpopulations underlying a psychometric

continuum. Implications for DSM-V, DSM-VI, and DSM-VII. Annual Review of Clinical

Psychology, 6, 391–419.

Luhrmann, T. M. (2007). Social defeat and the culture of chronicity: or, why schizophrenia does

so well over there and so badly here. Culture, Medicine and Psychiatry, 31(2), 135–172.

Metzl, J. (2009). The protest psychosis: How schizophrenia became a black disease. Beacon

Press Boston, MA. Retrieved from

http://archpedi.jamanetwork.com/data/Journals/JAMA/4513/jbk0519_1984_1984.pdf

Minsky, S., Vega, W., Miskimen, T., Gara, M., & Escobar, J. (2003). Diagnostic patterns in

Latino, African American, and European American psychiatric patients. Archives of

General Psychiatry, 60(6), 637–644.

Miranda, J., McGuire, T., Williams, D., & Wang, P. (2008). Mental health in the context of

health disparities. American Journal of Psychiatry, 165(9), 1102–1108.

Monroe, S. M. (1983). Major and minor life events as predictors of psychological distress:

Further issues and findings. Journal of Behavioral Medicine, 6(2), 189–205.

Morgan, C., Fisher, H., Hutchinson, G., Kirkbride, J., Craig, T. K., Morgan, K., … others.

(2009). Ethnicity, social disadvantage and psychotic-like experiences in a healthy

population based sample. Acta Psychiatrica Scandinavica, 119(3), 226–235.

Morgan, C., Kirkbride, J., Hutchinson, G., Craig, T., Morgan, K., Dazzan, P., … others. (2008).

Cumulative social disadvantage, ethnicity and first-episode psychosis: a case-control

study. Psychological Medicine, 38(12), 1701–1715.

Myin-Germeys, I., & van Os, J. (2007). Stress-reactivity in psychosis: evidence for an affective

pathway to psychosis. Clinical Psychology Review, 27(4), 409–424.

Oh, H., DeVylder, J. E., & Chen, F. (2014). To Treat or Not to Treat: Responding to Psychotic

Experiences. British Journal of Social Work, bct199.

Oh, H., Yang, L. H., Anglin, D. M., & DeVylder, J. E. (2014). Perceived discrimination and

psychotic experiences across multiple ethnic groups in the United States. Schizophrenia

Research. Retrieved from

http://www.sciencedirect.com/science/article/pii/S092099641400228X

Paradies, Y. (2006). A systematic review of empirical research on self-reported racism and

health. International Journal of Epidemiology, 35(4), 888–901.

Pearlin, L. I., & Bierman, A. (2013). Current issues and future directions in research into the

stress process. In Handbook of the sociology of mental health (pp. 325–340). Springer.

Retrieved from http://link.springer.com/chapter/10.1007/978-94-007-4276-5_16

Pearlin, L. I., Menaghan, E. G., Lieberman, M. A., & Mullan, J. T. (1981). The stress process.

Journal of Health and Social Behavior, 337–356.

Pennell, B.-E., Bowers, A., Carr, D., Chardoul, S., Cheung, G., Dinkelmann, K., … Torres, M.

(2004). The development and implementation of the national comorbidity survey

replication, the national survey of American life, and the national Latino and Asian

American survey. International Journal of Methods in Psychiatric Research, 13(4), 241–

269.

Phelan, J. C., Link, B. G., Diez-Roux, A., Kawachi, I., & Levin, B. (2004). “Fundamental

causes” of social inequalities in mortality: a test of the theory. Journal of Health and

Social Behavior, 45(3), 265–285.

Reininghaus, U., Craig, T. K., Fisher, H. L., Hutchinson, G., Fearon, P., Morgan, K., … others.

(2010). Ethnic identity, perceptions of disadvantage, and psychosis: Findings from the

ÆSOP study. Schizophrenia Research, 124(1), 43–48.

Ridley, C. R. (1984). Clinical treatment of the nondisclosing Black client: A therapeutic paradox.

American Psychologist, 39(11), 1234.

Sellers, R. M., & Shelton, J. N. (2003). The role of racial identity in perceived racial

discrimination. Journal of Personality and Social Psychology, 84(5), 1079.

Selten, J.-P., & Cantor-Graae, E. (2005). Social defeat: risk factor for schizophrenia? The British

Journal of Psychiatry, 187(2), 101–102.

Selten, J.-P., & Cantor-Graae, E. (2007). Hypothesis: social defeat is a risk factor for

schizophrenia? The British Journal of Psychiatry, 191(51), s9–s12.

SHARPLEY, M. S., Hutchinson, G., MURRAY, R. M., & McKenzie, K. (2001). Understanding

the excess of psychosis among the African—Caribbean population in England Review of

current hypotheses. The British Journal of Psychiatry, 178(40), s60–s68.

Sharpley, M. S., & Peters, E. R. (1999). Ethnicity, class and schizotypy. Social Psychiatry and

Psychiatric Epidemiology, 34(10), 507–512.

Sohler, N. L., & Bromet, E. J. (2003). Does racial bias influence psychiatric diagnoses assigned

at first hospitalization? Social Psychiatry and Psychiatric Epidemiology, 38, 463–472.

Swim, J. K., Hyers, L. L., Cohen, L. L., Fitzgerald, D. C., & Bylsma, W. H. (2003). African

American college students’ experiences with everyday racism: Characteristics of and

responses to these incidents. Journal of Black Psychology, 29(1), 38–67.

Takayanagi, Y., Spira, A. P., Roth, K. B., Gallo, J. J., Eaton, W. W., & Mojtabai, R. (2014).

Accuracy of Reports of Lifetime Mental and Physical Disorders: Results From the

Baltimore Epidemiological Catchment Area Study. JAMA Psychiatry, 71(3), 273–280.

Tandon, R., Keshavan, M. S., & Nasrallah, H. A. (2008a). Schizophrenia,“just the facts” what

we know in 2008. 2. Epidemiology and etiology. Schizophrenia Research, 102(1), 1–18.

Tandon, R., Keshavan, M. S., & Nasrallah, H. A. (2008b). Schizophrenia,“just the facts”: What

we know in 2008: Part 1: Overview. Schizophrenia Research, 100(1), 4–19.

Taylor, T. R., Kamarck, T. W., & Shiffman, S. (2004). Validation of the Detroit Area Study

Discrimination Scale in a community sample of older African American adults: the

Pittsburgh healthy heart project. International Journal of Behavioral Medicine, 11(2),

88–94.

Thornicroft, G., Brohan, E., Rose, D., Sartorius, N., & Leese, M. (2009). Global pattern of

experienced and anticipated discrimination against people with schizophrenia: a cross-

sectional survey. The Lancet, 373(9661), 408–415.

Üstün, T. B. (2010). Measuring health and disability: Manual for WHO disability assessment

schedule WHODAS 2.0. World Health Organization. Retrieved from

http://books.google.com/books?hl=en&lr=&id=h9fhLNiaRTgC&oi=fnd&pg=PR1&dq=u

stun,+2010+WHODAS&ots=6qI-9advGu&sig=XJSrxi-EuEIR7O11cUG6njCgt2g

Veling, W. (2013). Ethnic minority position and risk for psychotic disorders. Current Opinion in

Psychiatry, 26(2), 166–171.

Veling, W., Hoek, H. W., & Mackenbach, J. P. (2008). Perceived discrimination and the risk of

schizophrenia in ethnic minorities. Social Psychiatry and Psychiatric Epidemiology,

43(12), 953–959.

Veling, W., Selten, J.-P., Susser, E., Laan, W., Mackenbach, J. P., & Hoek, H. W. (2007).

Discrimination and the incidence of psychotic disorders among ethnic minorities in The

Netherlands. International Journal of Epidemiology, 36(4), 761–768.

Veling, W., Selten, J.-P., Veen, N., Laan, W., Blom, J. D., & Hoek, H. W. (2006). Incidence of

schizophrenia among ethnic minorities in the Netherlands: a four-year first-contact study.

Schizophrenia Research, 86(1), 189–193.

Waelde, L. C., Pennington, D., Mahan, C., Mahan, R., Kabour, M., & Marquett, R. (2010).

Psychometric properties of the Race-Related Events Scale. Psychological Trauma:

Theory, Research, Practice, and Policy, 2(1), 4.

Wagner, B. M., Compas, B. E., & Howell, D. C. (1988). Daily and major life events: A test of an

integrative model of psychosocial stress. American Journal of Community Psychology,

16(2), 189–205.

Werbeloff, N., Drukker, M., Dohrenwend, B. P., Levav, I., Yoffe, R., van Os, J., … Weiser, M.

(2012). Self-reported attenuated psychotic symptoms as forerunners of severe mental

disorders later in life. Archives of General Psychiatry, 69(5), 467–475.

Whaley, A. L. (2001). Cultural mistrust of white mental health clinicians among African

Americans with severe mental illness. American Journal of Orthopsychiatry, 71(2), 252.

Williams, D. R., & Mohammed, S. A. (2009). Discrimination and racial disparities in health:

evidence and needed research. Journal of Behavioral Medicine, 32(1), 20–47.

Williams, D. R., Yu, Y., Jackson, J. S., & Anderson, N. B. (1997). Racial differences in physical

and mental health socio-economic status, stress and discrimination. Journal of Health

Psychology, 2(3), 335–351.

Chapter IV: Immigration and psychotic experiences in the United States: Another example of the epidemiological paradox?

Introduction

The immigration risk for psychosis in Europe

In Europe, immigrants have higher rates of psychotic disorder when compared with native-born populations (Bhugra, 2000; Hutchinson & Haasen, 2004). This relationship is pronounced and widely established. Cantor-Graae and Selten's (2005) meta-analysis found that immigrants are 2.9 times more likely to develop schizophrenia than their native-born counterparts, which corroborates prior effect sizes reported in systematic reviews (McGrath et al., 2004; Saha et al., 2005). Interestingly, second generation immigrants, who by definition are excluded from many of the stressors associated with immigration, are approximately 4.5 times more likely to develop schizophrenia than non-immigrants (Cantor-Graae & Selten, 2005), which depicts a complex portrait of social risk factors that may be involved in shaping the habitus of psychosis for immigrants and their progeny over time (Bhugra, 2000).

Immigrants are at greatest risk for schizophrenia when relocating to European countries where they will be racial minorities (Selten et al., 2007). Black (especially darker-skinned) immigrants to Europe have much higher rates of psychosis when compared with white immigrants or nonwhite/nonblack immigrants (Cantor-Graae & Selten, 2005), even though psychosis rates are not relatively higher in the African or the Caribbean countries of origin

(Hickling & Rodgers-Johnson, 1995; Bhugra et al., 1996; Mahy et al., 1999; Saha et al., 2005). It appears that the context of the receiving society (i.e., whether it is favorable or adverse to a particular immigrant group) can interact with immigrant attributes (Schwartz et al., 2010), and can influence the morbidity of psychosis. As such, studies have also found that immigrants who

reside in areas consisting of high densities of their own ethnic groups often experience buffering effects from the social risk factors for psychosis (Boydell et al., 2001; Das-Munshi et al., 2012;

Kirkbride et al., 2007; Schofield et al., 2011; Veling, 2008). The interaction between immigrants and their contexts may help explain the absence of an immigration effect on schizophrenia incidence in Jerusalem (Corcoran et al., 2009).

Dealberto (2010) noted that risk for psychotic disorders may be pronounced in countries with longstanding immigration when compared with countries of recent immigration, but also noted the absence of recent data on this topic in the US, where there may be “a hidden epidemic of schizophrenia and psychosis in immigrants to North America,” (p. 1). However, research has yet to corroborate this supposition, and may suggest otherwise. In the US, immigrants have proven to be healthier than their native-born counterparts (Jasso et al., 2004), though much less evidence exists to confirm this resilience with respect to specific psychiatric diagnoses, raising uncertainty as to whether immigrants in the US are really in fact more vulnerable to psychosis.

The Epidemiological Paradox in the United States

For over half of a century, the US epidemiological literature has shown that Latino immigrants, who despite higher socioeconomic and demographic risk for disease and mortality, report similar or lower rates of several chronic health conditions and mental health outcomes when compared with native-born populations (Alegria et al., 2007b; 2008; Forbes and Frisbie

1991; Markides and Coreil, 1986). This phenomenon was dubbed ‘the Latino paradox’, and prompted researchers to wonder whether there was something uniquely salutary about Latino culture. However, subsequent studies began to observe resilience among other ethnic groups in the US (Singh & Hiatt, 2006) and in Canada (Beiser et al., 2002; Hyman 2000; Hyman &

Dussault, 1996; Landale et al. 1999; McDonald and Kennedy 2004; Nair et al., 1989; Newbold

2005; Newbold 2006; Newbold & Danforth 2003; Rumbaut and Weeks, 1996), revealing a pattern that now stretches across diverging cultural spaces and social realities. Researchers have attempted to explain this broader epidemiological paradox by examining selection and acculturation.

Selection

Selection occurs when individuals who decide to migrate are healthier than those who remain in the countries of origin (the healthy migrant effect) or when unhealthy immigrants in the US return to their home countries (salmon bias). Studies have both discounted and supported selection as an explanatory mechanism for the epidemiological paradox. In a seminal study,

Abraido-Lanza and colleagues (1999) analyzed Latino sub-groups with differing propensities for selective migration and found that selection as a whole could not consistently and parsimoniously explain the mortality advantage among Latino immigrants. Subsequent studies have found weak support for the healthy migrant effect on health status (e.g. Rubalcava et al.,

2008; Auger et al., 2008) and small effects of the salmon bias on mortality among Latinos (e.g.

Palloni & Arias, 2004; Turra & Elo, 2008).

On the other hand, studies have shown that immigrants often report better health when compared with US native-born populations even though the health statuses in the countries of origin are below that of the US (Jasso et al., 2004). Throughout the 20th century, national origin quotas and other US policies restricted immigration from various regions of the world, favoring the admission of skilled professionals and entrepreneurs. Immigrants would have been selected based on their individual skill, the value and transferability of that skill in the US, and the labor

supply/demand in the sending and receiving countries. Skilled professionals and entrepreneurs have higher education levels, which is associated with positive health status (educated people have greater access to health care, are more likely to make informed decisions about utilizing medical services, are more inclined to implement self-care, and are more likely to avoid harmful behaviors). Skilled, educated, and healthy individuals have stronger earnings capacity, increasing the prospects and overall likelihood of immigration. Further, US physicians were enlisted to screen for diseases, substance use, and mental disorders, denying entry to those who were sick or illiterate (Wright, 2008).

The favorable economic conditions in the U.S. also drew immigrants who did not have high levels of education or professional skills, including undocumented immigrants, those seeking reunification with family members, or those escaping the adverse conditions of their countries of origin (refugees and asylees). These immigrants would likely have poorer health trajectories when compared with native-born populations. Still, unhealthy people would have been less capable of completing such an arduous journey (especially when traveling from a developing nation to a developed nation), perhaps even more so for individuals coping with symptoms of psychosis (Cantor-Graae and Selten, 2005). Selection may be particularly strong for individuals with schizophrenia since the average age of onset is much earlier relative to other chronic health conditions (arthritis, diabetes, hypertension, heart disease, etc.).

Acculturation

Studies suggest that the superior health status of immigrants begins to deteriorate after settlement in the receiving country (Kitagawa & Hauser, 1973; Marmot et al., 1975), though there is some debate as to whether this is actually true given the lack of long-term empirical

evidence (Jasso et al., 2004). Still, several studies have found that higher levels of acculturation have been associated with negative mental health outcomes. Schwartz and colleagues (2010) recast the concept of acculturation to encompass multiple dimensions, including practices, values, and identifications of both sending and receiving countries, which must be negotiated within a social context. Conceivably, acculturative processes may work differently across racial/ethnic categories, depending on the context of reception. In other words, some immigrant groups are received more negatively than others (e.g. Mexican immigrants may be treated as

‘illegal aliens’ and Middle Eastern immigrants may be treated as ‘terrorists’; Nacos & Torres-

Reyna, 2006; Nevins 2002), and so the immigrant’s characteristics must be examined with respect to the immigrant’s fit and location within the racial hierarchy of the US (Ford & Harawa,

2010).

Health status decline may be attributable to (1) the loss of traditional cultural practices from the country of origin, (2) the acquisition of host society cultural practices, or (3) a combination of the two (Schwartz et al., 2010). In theory, heritage cultures might promote exercise and a wholesome diet (Corral & Landrine, 2008; Unger et al., 2004), and encourage a lifestyle that is more salutary than the typical American lifestyle (Vega and Amaro, 1994).

Moreover, heritage cultures may value collectivism over individualism, fostering robust social support networks, and curbing risky behaviors, such as smoking, drinking, and substance use

(Allen et al., 2008; Johnson, 2007; Lara et al., 2005; Le & Kato, 2006; Nasim et al., 2007; Oetzel et al., 2007). Conceivably, the longer immigrants stay in the US, the more they lose these protective effects, and the more they begin to adopt the deleterious habits of the host society.

The second generation of immigrants may be more susceptible to acculturative effects.

The stressors of being an immigrant —such as being mistreated because of one’s accent or

limited English proficiency, being questioned about one’s legal status, feeling guilt about leaving one’s family in country of origin, being afraid of deportation, and so forth — appear to increase risk for psychotic experiences among Latino and Asian immigrants in the United States

(DeVylder et al., 2013). However, second generation immigrants would not be exposed to many of these stressors, but would still encounter discrimination, alienation, identity crises, and other stressful events. Concurrently, the protective attributes of their heritage culture dissipate, which then may result in greater risk for psychopathology (e.g. Kaplan and Marks, 1990).

Burnam and colleagues (1987) found second-generation Mexican Americans with high levels of acculturation had higher lifetime prevalence of mood, anxiety, and substance use disorders when compared with first-generation Mexican-Americans. Williams and colleagues

(2007) analyzed the National Survey of American Life (NSAL) and found that first-generation

Caribbean Blacks had lower rates of mood, anxiety, and substance use disorders when compared with second and especially third-generation Caribbean Blacks, likely due to acculturative effects.

Acculturation has also been associated with increased distress and depression in Asian

Americans (Mak et al., 2005; Nguyen and Peterson, 1993).

Psychotic experiences

Epidemiological studies have repeatedly found that people report psychotic experiences without reporting distress and impairment that would constitute a psychiatric disorder, revealing a continuum of the psychosis phenotype. While psychotic disorder occurs in about 1% of the population, sub-clinical psychotic experiences (PE) have been reported by upwards of 7.2% of the general healthy population (Linscott and van Os, 2013). PE may produce clinically significant distress and help-seeking behaviors (DeVylder et al., 2014a; Murphy et al., 2010; Oh et al., 2014; Yung et al., 2006; Armando et al., 2010), and may possess some limited utility in

predicting onset of full psychotic disorder (Fisher et al., 2013; Kaymaz et al., 2012; Werbeloff et al., 2012).

Research on migration and psychosis in Europe has focused primarily on psychotic disorders and not on PE. A notable exception is King and colleagues’ (2005) study that analyzed a community-based probabilistic sample of 4281 adults, and found higher prevalence of psychotic symptoms among multiple immigrant groups (except among Bangladeshis) in the UK when compared with native-born populations. Their study did not stratify by generation, but did show that the associations between immigration and psychotic symptoms mirror the associations between immigration and full psychotic disorder in Europe. A similar finding emerged in

Australia (Scott et al., 2006); however, Vega and colleagues (2006) did not find this same association among Mexican-Americans. To my knowledge, Vega and colleagues are the only researchers to have examined the association between immigration and PE in the US, and their findings show that when compared with native-born populations, immigrants reported lower rates of psychotic experiences.

Aims and hypotheses

The psychosis literature from Europe and the epidemiological paradox literature from the

US lead us to two competing hypotheses: (1) Given the robust findings that immigration is a risk factor for psychosis in Europe, I would expect similar relationships to be present in the US; however, (2) Findings that immigration appears to be a protective factor for several mental health conditions in the US suggest that this paradox may extend to psychosis as well.

Furthermore, differential effects of selection and acculturation across ethnic groups are unknown, but may hinge on the reasons for migration and the varying levels of supports

available upon arrival to the US. This study analyzes one nationally representative sample and three race/ethnicity-specific national household probability samples, exploring the overall relationship between immigration and PE in the US, as well as the variability of this relationship across ethnic/racial groups.

Methods

Participants

I separately analyzed four samples from the Collaborative Psychiatric Epidemiology

Surveys (CPES; Alegría et al. 2007), which consists of three US population-level surveys: (1) the

National Comorbidity Survey Replication (NCS-R; Kessler et al. 2004), (2) the National Latino and Asian American Study (NLAAS; Alegría et al. 2004) and (3) the National Survey of

American Life (NSAL; Jackson et al. 2004), following a previously utilized analytic plan

(DeVylder et al., 2014b). All surveys used similar methodology and multi-stage sampling designs, drawing adult participants from households in the 48 contiguous states.

The NCS-R (years 2001- 2002) is a nationally representative survey of 9282 individuals

(predominantly White, reflecting the general population of the USA), of which a random subsample (n =2322) completed the psychosis screen. The NLAAS (years 2002-2003) is a survey of Latino (n = 2554) and Asian (n = 2095) Americans, which for the purposes of this study was analyzed as two separate subsamples divided by ethnicity. Finally, the NSAL (years

2001 –2003) is a nationally representative sample of African-Americans (n=3570), with Afro-

Caribbean (n=1621) and Caucasian (n=891) respondents drawn from the same source neighborhoods, though Caucasians did not receive the psychosis screen. Response rates were

70.9% for the NCS-R, 75.5% for the NLAAS Latino sample, 65.6 % for the NLAAS Asian

sample, and 72.3% for the NSAL, which are consistent with other large-scale psychiatric epidemiology studies. Participants with missing data for any of the variables of interest, including socio-demographic confounders, were excluded. After exclusion, the analytic sample sizes were: NCS-R (nationally representative, predominantly White) (n=2292), NLAAS Latino

(n=2539); NLAAS Asian (n=2089), and NSAL (Black American) (n= 4906).

Measures

WHO-CIDI 3.0 Psychosis Screen

PEs were assessed using the WHO-CIDI 3.0 psychosis screen, which included items assessing: (1) visual hallucinations, (2) auditory hallucinations, (3) thought insertion, (4) thought control, (5) telepathy and (6) delusions of persecution. PE were excluded if the experience took place solely in the context of falling asleep, dreaming, or substance use. The psychosis screen elicited lifetime and 12-month occurrence of any of the six experiences. 12-month occurrence captures recent PE and tends to be more reliable than lifetime estimates (Takayanagi, 2014), and likely occur after immigration, since most people in the samples have lived in the US for longer than one year. However, 12-month measures are confounded by persistence, which makes lifetime occurrence valuable.

Immigration Status

I examine generational status (first, second, third+) using a variable that asked respondents how many of their parents were born in the US; I coded immigrants as first generation, individuals who reported ‘none’ or ‘one parent’ as second generation, and individuals with two parents as third generation or older. My study also examined ‘duration of residency in the US’ (US-born, less than 5 years, 5-10 years, 11-20 years, 20+ years) as a proxy for

acculturation (Gee et al., 2009), as well as ‘age of immigration’ (US-born, under 12 years, 13-17 years, 18-34 years, 35+ years) in order to situate immigration as a major event within the developmental stages of the life course and to detect the delayed effects of immigration. The

NLAAS contained all three immigration measures; however, the NCS-R only contained a measure on generational status, while the NSAL public version contained all measures except generational status.

Covariates

Demographic variables (race/ethnicity, gender, age, marital status) were self-reported by respondents and were included in the adjusted models. Most studies conducted in Europe did not adequately account for socioeconomic status (SES), and so the present study controls for education and employment status. I included additional covariates in my analyses, which were income-to-poverty ratio (0, 1-2, 3+) as well as region of the country (Northeast, Midwest, South,

West), which tend to correlate with urbanicity.

Analyses

All analyses were conducted using the complex sample features of Stata SE version 13

(Stata Corporation, USA). I used sampling weights that corresponded with each survey to account for individual-level sampling factors including non-response and unequal probabilities of selection. Design-based analyses with Taylor series linearization were used to estimate standard errors that accounted for the complex multistage clustered design of each survey.

I reported descriptive data for migration variables and prevalence of PEs across all fmy samples, and I calculated odds ratios using blocked logistic regression. In the first block, I

examined the associations between PE and all immigration variables that were available in each dataset (generational status, duration of residency in the US, age of immigration) controlling for age, gender, and marital status. In light of an early study that found differences between immigrants and non-immigrants were insignificant after controlling for SES (Murphy, 1973), and that the majority of studies on migration and psychosis conducted in Europe overlooked SES

(Cantor-Graae and Selten, 2005), the second block added SES measures, including education, income-to-poverty ratio, region of country, and employment status. Statistical significance was assessed for all tests using Wald χ2, α=0.05. Effect sizes for adjusted multi-variable logistic regression analyses were reported as odds ratios (ORs) with 95% confidence intervals (CIs).

Results

Demographics and Prevalence of Psychotic Experiences

Weighted demographic data, including age, gender, marital status, income to poverty ratio, and region of the country, are presented in Table 1. Lifetime and 12-month prevalence of psychotic experiences among U.S.-born and immigrant groups in each data set are presented in

Figure 1. Logistic regression analyses testing for differences in psychosis prevalence by immigration status was examined independently for each data-set, with findings presented below.

Table 1. Descriptive data for migration variables and PE for each data set

NCS-R (N=2292) NLAAS - Latino NLAAS -Asian NSAL Generational Status

First 6.93 (0.97) 58.42 (2.32) 76.96 (3.01) 5.5 (0.41)

Second 11.36 (1.13) 21.10 (1.06) 13.67 (1.75) -

> Third 81.71 (1.84) 20.48 (1.55) 9.37 (1.45) -

Years in the US US-born 41.58 (2.32) 23.04 (3.01) 94.5 (0.41) < 5 9.69 (1.28) 14.19 (1.83) 1.31 (0.25) 6-10 9.09 (0.97) 12.08 (1.09) 1.06 (0.18) 11-20 18.39 (1.21) 26.40 (1.83) 1.36 (0.15) >21 21.24 (0.96) 24.28 (1.37) 1.76 (0.15) Age at time of immigration US-born 41.58 (2.32) 23.04 (3.01) 94.5 (0.41) < 12 12.24 (0.79) 12.74 (1.27) 0.93 (0.00) 13-17 10.97 (1.08) 5.09 (0.59) 0.83 (0.15) 18-34 28.73 (1.56) 4.17 (2.24) 2.77 (0.31) >35 6.48 (0.65) 17.42 (1.9) 0.97 (0.15) Psychotic Experiences Yes 9.03 (0.92) 9.59 (0.72) 6.88 (0.60) 11.80 (0.77)

No 90.97 (0.92) 90.41 (0.72) 93.12 (0.60) 88.20 (0.77)

Values for categorical variables given as weighted percentage (standard error).

Table 2. Demographic variables by each data set

NCS-R (N=2292) NLAAS-Latino NLAAS-Asian NSAL Race

White 72.65 (2.48) - - *

African- 12.61 (1.54) - - 93.18 (0.47) American Asian 1.32 (0.29) - - -

Latino 11.21 (1.68) - - -

Other 2.21 (3.80) - - -

Caribbean - - - 6.82 (0.47)

Chinese - - 28.59 (2.51) -

Vietnamese - - 12.97 (1.95) -

Filipino - - 21.55 (2.35) -

Other Asian - - 36.89 (2.25) -

Mexican - 56.53 (3.68) - -

Puerto Rican - 9.99 (1.0) - -

Cuban - 4.65 (0.50) - -

Other Latino - 28.83 (2.88) - -

Gender

Male 47.63 (1.47) 51.55 (1.24) 47.41 (1.13) 44.32 (0.83)

Female 52.37 (1.47) 48.45 (1.24) 52.59 (1.13) 55.68 (0.83)

Age

18-29 22.34 (1.37) 35.14 (1.46) 26.48 (1.49) 25.48 (1.12)

30-44 28.89 (1.24) 36.02 (1.04) 35.51 (1.76) 35.16 (0.95)

45-59 23.62 (1.30) 18.26 (0.93) 23.99 (1.04) 23.45 (0.82)

60+ 25.16 (1.71) 10.58 (0.92) 14.03 (1.94) 15.91 (0.83)

Marital Status

Married 55.79 (1.67) 64.39 (1.38) 69.06 (1.67) 41.89 (1.02)

Table 2. Demographic variables by each data set

Never 21.55 (1.35) 20.99 (1.19) 22.41 (1.32) 31.96 (1.27) Married Previously 22.66 (1.36) 14.63 (1.02) 8.53 (0.95) 26.15 (0.78) Married Education

Less than 18.55 (1.39) 44.3 (1.77) 15.20 (1.50) 24.18 (1.12) high school High school 33.13 (1.27) 24.58 (0.93) 17.55 (1.24) 37.05 (1.01)

Some 25.82 (1.08) 20.90 (1.33) 25.18 (1.51) 24.33 (0.98) college College or 22.50 (1.46) 10.21 (1.02) 42.08 (2.04) 14.44 (1.03) beyond Employment

Employed 61.68 (1.55) 63.57 (1.72) 63.90 (1.40) 67.23 (1.03)

Unemployed 6.32 (0.77) 7.47 (0.90) 6.39 (0.73) 10.31 (0.71)

Out of labor 32.01 (1.36) 28.96 (1.87) 29.71 (1.48) 22.46 (0.96) force Income Poverty Ratio 0 7.33 (0.90) 15.86 (1.31) 12.11 (1.02) 9.52 (0.74)

1-2 29.31 (1.47) 40.57 (1.56) 20.15 (1.25) 49.61 (1.28)

3+ 63.36 (1.69) 43.57 (2.13) 67.74 (1.72) 40.88 (1.56)

Region

Northeast 18.79 (3.00) 18.54 (1.78) 15.71 (3.55) 18.8 (1.02)

Midwest 22.82 (1.72) 8.34 (1.59) 8.77 (2.03) 16.73 (1.36)

South 37.16 (2.23) 30.51 (4.49) 7.86 (1.81) 54.67 (2.12)

West 21.22 (1.60) 42.61 (4.21) 67.66 (4.27) 9.80 (0.93)

Values for categorical variables given as weighted percentage (standard error). *Whites in the NSAL were dropped because they did not complete the psychosis screen

NCS-R

The vast majority of respondents in the NCS-R were native born, with family history in the US for at least three generations. 6.93% of the weighted sample was first generation immigrants, while 11.36% was second generation immigrants. Adjusted multivariable logistic regression models showed that in the NCS-R, first and second generation immigrants were not significantly more likely to report lifetime PE than individuals who have been in the US for three generations or more, though first generation immigrants were 2.8 times more likely to report 12 month PE (Table 3). Sub-analysis of only white respondents yielded odds ratios of similar magnitude and direction for 12-month PE, but effects were non-significant (results available upon request).

Table 3. Multivariable logistic regression models depicting associations between generational status and psychotic experiences in the National Comorbidity Survey - Replication (N=2292) Lifetime PE 12-month PE OR (95% CI) Generational Status

> Third 1.00 1.00

Second 1.33 (0.82- 2.18) 1.45 (0.69-3.07)

First 1.17 (0.61- 2.23) 2.80 (1.18-6.64)

Adjusted for race, age, gender, marital status, education, income-to-poverty ratio, region of country, and employment status.

NLAAS

In the NLAAS, 58.42% of Latino respondents were first generation immigrants, while

21% were second generation, and 20.48% were third or more. Among Latinos, first generation immigrants were not significantly more likely to report PE when compared with the third (or more) generation, and were significantly less likely to report 12-month PE. Second generation

immigrants were also not at any greater risk when compared with older generations. When compared with the native-born population, living in the US for 6–10 years after immigration was associated with a 40% decreased probability of reporting lifetime PE, and living in the US for 21 or more years was associated with a 70% decreased probability of reporting 12-month PE, while immigrating between the ages of 18 and 34 was associated with decreased likelihood of reporting both lifetime and 12-month PE. Latinos from the Caribbean (Cubans and Puerto Ricans) and

Other Hispanics were more likely to report PE when compared with Mexicans.

For Asian respondents, 76.96% were first-generation immigrants, while 13.67% were second generation, and 9.37% were third or more. Amongst Asians, neither generational status

(first/second vs. third or more) nor duration living in the US yielded any significant findings.

Immigrating during or after the age of 35 was associated with a decreased likelihood of reporting lifetime PE. Filipinos and ‘other Asians’ were more likely to report PE when compared with

Chinese.

Post-hoc unconditional subpopulation analyses (available upon request) yielded insignificant results due to lack of power, but effect sizes seemed to resemble the effect sizes in the larger analyses in terms of magnitude and direction, favoring the existence of a paradox within each Latino ethnic group (with the exception of Puerto Rican, which yielded highly insignificant effect sizes that suggested Puerto Rican immigrants were at greater risk for PE) and within each Asian ethnic group.

Table 4. Multivariable logistical regression models depicting associations between immigration and lifetime psychotic experiences among Latinos (N=2539) in the National Latino and Asian American Survey Lifetime 12-month Lifetime 12-month Lifetime 12-month OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Ethnicity Mexica 1.00 1.00 n Cuban 2.51 (1.54-4.11) 5.15 (2.14- 12.35) Puerto 1.89 (1.17-3.06) 2.57 (1.29-5.12) Rican Other 1.51 (1.04-2.19) 1.14 (0.61- Hispani 2.14) c Generational Status >Third 1.00 1.00 Second .87 ( 0.52-1.46) .46 (.21-1.05) First .65 (0.34-1.25) .34 (0.20-0.56) Years in the US US- 1.00 1.00 born < 5 .73 ( .33-1.65) .51 (0.10-2.70) 6-10 .59 (0.37- 0.92) .60 (0.20-1.83) 11-20 .78 (.40-1.55) .74 (0.39-1.41) >21 .65 (.40-1.07) .27(0.13-0.54) Age at time of immigration US- 1.00 1.00 born < 12 1.06 (.60-1.89) .47 (0.22-0.10) 13-17 .69 (0.39-1.21) .58 (0.24-1.40) 18-34 .51 (.27-0.94) .46 (0.26-0.83) >35 .60 (0.30-1.18) .46 (0.19-1.10)

Adjusted for age, gender, marital status, education, income-to-poverty ratio, region of country, employment status

Table 5. Multivariable logistical regression models depicting associations between immigration and lifetime psychotic experiences among Asians (N=2089) in the National Latino and Asian American Survey Lifetime 12-month Lifetime 12-month Lifetime 12-month OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Ethnicity Chinese 1.00 1.00 Filipino 2.026 ( 1.10- .72 (0.21-2.41) 3.74) Vietna 1.01 (0.45-2.28) .52 (0.16-1.70) mese Other 2.29 (1.33-3.95) 1.07 (0.41-2.81) Asian Generational Status >Third 1.00 1.00 Second 1.02 (0.37-2.80) .72 (0.19-2.73) First .82 (.36-1.86) 1.28 (0.60-2.76) Years in the US US- 1.00 1.00 born < 5 .56 (0.27-1.19) 1.34 (0.33-5.44) 6-10 .64 (0.38-1.07) .78 (0.26-2.32) 11-20 .99 (0.55-1.77) 1.49 (0.37-5.84) >21 .86 (0.46-1.60) 2.05 (0.72-5.85) Age at time of immigration US- 1.00 1.00 born < 12 1.04 (0.48-2.28) 1.88 (.48-7.39) 13-17 .37 (.08-1.62) .39 (0.05-3.15) 18-34 0.85 (0.53-1.35) 1.82 (0.63-5.21) >35 .41 (0.18-0.94) .42 (.06-3.13)

Adjusted for age, gender, marital status, education, income-to-poverty ratio, region of country, and employment status.

NSAL

In the NSAL, 5.5% of Black Americans were first-generation immigrants, most of whom were Black Caribbean (almost 70% of the Black Caribbean sample in the NSAL were foreign- born). Being an immigrant was not significantly associated with an increased likelihood of reporting a lifetime or 12-month PE. Individuals who have been living in the U.S. for 21 years or longer after immigration, as well as those who immigrated during or after the age of 35 were significantly less likely to report lifetime PE when compared with native-born individuals. There were no differences in risk between African-Americans (most of whom were first-generation immigrants) and Black Caribbean Americans (the vast majority of whom were native-born).

Table 6. Multivariable logistic regression models depicting associations between nativity and lifetime psychotic experiences among Black Americans (N=4906) in the National Survey of American Life Lifetime 12-month Lifetime 12-month Lifetime 12-month OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) Ethnicity African 1.00 1.00 Americ an Caribbe 1.14 (0.73-1.77) 1.90 (0.86-4.18) an Black Nativity US- 1.00 1.00 born Immigr .67 (0.31-1.44) .60 (0.22-1.60) ant Years in the US US- 1.00 1.00 born < 5 .93 (0.29-3.0) .91 (0.24-3.39) 6-10 .98 (0.39-2.49) .74 (0.28-1.90) 11-20 .38 (0.14-1.05) .35 (0.06-1.94) >21 .42 (0.23-0.77) .53 (0.21-1.31) Age at time of immigration US- 1.00 1.00 born < 12 .82 (0.34-1.95) 1.27 (0.38-4.27) 13-17 .85 (0.27-2.62) .66 (0.18-2.41) 18-34 .71 (0.25-2.03) .45 (0.12-1.68) >35 .28 (0.14-0.56) .36 (0.11-1.16)

Adjusted for age, gender, marital status, education, income-to-poverty ratio, region of country, employment status

Discussion

Extant literature did not lead to a clear prediction regarding the type of association that would emerge between immigrant status and PE in the US. On one hand, immigrants might be at

higher risk for PE when compared with native-born populations, just as I would find in Europe.

On the other hand, immigrants might be at lower risk for PE, just as I would expect given the overall resilience of US immigrants. My results confirmed that when compared with native-born populations, immigrants are not at any greater risk for PE, and are in some cases at lower risk depending on age of immigration and duration of residency. This finding held true across cultures and across various geographic areas, providing yet another example of the epidemiological paradox. To my knowledge, my paper is only the second study to examine PE and immigration in US samples and the first to look at the association across multiple racial/ethnic groups.

The anomaly in my findings is that in the predominantly white sample (NCS-R), immigration was associated with increased risk for 12-month occurrence of PE. In other words, white immigrants were significantly more likely to endorse recent or persistent forms of PE, consistent with relationships found in Europe, a pattern not found in any other ethnic group immigrating to the United States. It is possible that because of the ethnic origin quotas enacted throughout the 20th century that favored European immigrants over Asian and Latino immigrants, selection effects may have been weaker for the NCS-R sample. However, due to societal and systemic discrimination based on skin color, European immigrants with lighter skin color would have also likely been more favorably received in the US when compared with immigrants from other parts of the world.

I found a high level of within-group variation when examining risk for PE among Latino populations. Latinos from the Caribbean (Cubans and Puerto Ricans) and Other Hispanics were more likely to report PE when compared with Mexicans. This aligns with prior studies that show a mortality advantage among foreign born Mexicans and other Latinos, but not Cubans or Puerto

Ricans (Palloni and Arias, 2004). Previous studies also suggest Cubans tend to have higher rates of mood disorders and Puerto Ricans tend to have higher rates of any psychiatric disorder

(particularly anxiety disorder) when compared to other Latino groups (Alegria et al., 2008).

Some of these subgroup differences may be due to selection effects stemming from facing lower or higher barriers to entering the US. Using Mexicans as a comparison group, for example,

Puerto Ricans and Cubans face lower barriers to entry into the country, since Puerto Rico is an unincorporated US territory, and the Cuban Adjustment Act facilitates the process of becoming a permanent resident. By comparison, Mexicans may be subject to a stronger selection effect because they encounter more restrictive immigration policies.

In a similar vein, I found that Other Asians and Filipinos were twice as likely to report lifetime PE when compared with Chinese. Again, varying restrictions in US immigration policies may account for some of the within-group differences among Asian American populations, as for

Latino populations. Filipinos have a unique history in that they were considered US nationals and therefore did not encounter the same immigration restrictions that impeded other Asian groups. And so by comparison, Chinese immigrants may have been subjected to a stronger selection effect. However, Filipinos have greater exposure to American culture (e.g. language) through their education system, closing much of the cultural distances between the US and the

Philippines (Starr, 2009), which may also have resulted in a weaker acculturation effect.

Interestingly, across ethnic groups, I found that after immigration, longer duration in the

US may actually be protective against PE in some instances. This is an unexpected finding, since in theory, the protective effects of heritage culture should still be active upon settlement in a new country, but should wane over time as the inimical effects of acculturation set in. My findings may be capturing the reality that recent immigrants face a number of acculturative stressors that

increase risk for PE (see DeVylder et al., 2013), including language difficulties (Yoo et al.,

2009), that may become less salient the longer the immigrants stay in the country.

Those who immigrated at an older age tended to have lower risk for PE when compared with their non-immigrant counterparts. Psychosis tends to emerge in young adulthood for the first time, and older immigrants would have passed the age range at which the risk of psychosis emerging is highest. However, it is also possible that this could be because individuals who immigrate later in adulthood have spent a substantial portion of their lives in their countries of origin, and thus may be more likely to resist acculturation processes (Schwartz et al., 2006). For example, older immigrants might be less inclined to adopt the practices, values, or identifications of the host society when compared with younger immigrants (Schwartz et al., 2010).

Limitations and Future Directions

Interpretation of my findings should be made bearing in mind a number of potential limitations. In order to most accurately examine the effects of selective immigration on PE, I would need to know whether rates of psychosis were any higher or lower in the general populations of the various sending countries relative to the US, and I would need to compare US immigrants with individuals who remained in their respective countries of origin at the time of immigration. Current cross-national prevalence rates vary widely across countries (0.8% to

31.4%; Nuevo et al., 2010) even when using the same measure, making it difficult to interpret the extent to which these figures represent true prevalence rates versus differences in item interpretation (i.e., cultural validity of the measure), and therefore, limiting cross-national comparisons. Ideally I would want to measure health status the moment immigrants first arrive, and then track immigrant cohorts longitudinally, accounting for the pure cohort and aging effects. I were unable to capture the life cycles of the respondents given the cross-sectional

nature of the data. Furthermore, I did not account for return migration to rule out salmon bias, as immigrants can come to the US temporarily and return to their countries of origin, especially if they become ill.

Future research should take into account the historical context and timing of immigration.

The variegation of US immigration legislation has impacted groups unevenly and non- concurrently, obfuscating whether selection applies to all cohorts from all countries. The epidemiological paradox has also emerged in certain parts of Europe and Australia, at least with respect to physical health outcomes (Bennett, 1993; Guendelman et al. 1999; Swerdlow 1991;

Williams 1993; Razum et al. 1998, 2000), and so comparing immigration policies with these countries can be illuminating. However, few studies have confirmed the existence of the epidemiological paradox with respect to mental health outcomes outside of North America, with the exception of Corcoran and colleagues (2009) who found that second-generation immigrants in Israel did not have higher risk for psychotic disorder.

The magnitude of health selection can vary systematically from country to country. That is to say, the probabilities of immigrating to Europe versus the US are different, and depend on a number of factors, such as geographic distance, sociopolitical conditions, as well as the cultural similarities of the sending and receiving countries. My study did not address why immigrants specifically came to the US over any other country. The answer is complex and involves push factors (e.g. war, famine, persecution) and pull factors (access to quality health care, economic opportunity), which can influence health trajectories. For instance, voluntary migrants who were pulled to the US as skilled professionals are likely to have had higher education and greater access to preventative care, and thus better health. Meanwhile, refugees or asylees who were pushed out of their countries due to ongoing civil unrest may have been exposed to trauma,

resulting in elevated risk for PE. Future studies should account for visa statuses or categories of immigrants (e.g. citizens, permanent residents, short-term unskilled contract laborers, refugee, asylee, undocumented) as these groups have varying levels of resources and exposures to stressors.

The amount of social support available to the immigrant upon arrival depends on how large, well established, and connected the immigrant group is in the US. Asylees and refugees are likely to come from low socioeconomic status and are less likely to have support systems in the country of settlement (Steiner, 2009). Recent trends are beginning to reveal that immigrants in the US are settling in non-traditional communities where there are minimal histories of immigrant settlement, limiting the social infrastructure and support available to immigrants

(Lichter, 2009). Prior studies have shown that being in an ethnic enclave can help preserve the heritage culture and buffer the adverse effects of acculturation and other stressors (Schwarts et al., 2006; Eschbach et al., 2004). It is possible that this shift will begin to counter the epidemiological paradox in coming years and decades.

Overall, I did not find that acculturation had an effect on risk for PE in the US; however,

I made inferences based on age of immigration and duration living in the US without using explicit measures of acculturation. Thus, contextual factors may still play a key role in explaining the differences in prevalence rates of psychosis between the US and Europe. If this is in fact the case, then interventions may endeavor to shape the context of reception for immigrants by tailoring services and resources to accommodate the characteristics if immigrant populations (i.e. national origin, visa status, the communities in which they settle, socioeconomic status, social networks, and language fluency). These efforts may reduce a sense of defeat and

foster greater acceptance into the country during and beyond the immigration process, thereby influencing the secular trends of psychotic morbidity.

References

Abraído-Lanza, A.F., Chao, M.T., Flórez, K.R., 2005. Do healthy behaviors decline with greater

acculturation?: Implications for the Latino mortality paradox. Social science and

medicine 61, 1243–1255.

Abraido-Lanza, A.F., Dohrenwend, B.P., Ng-Mak, D.S., Turner, J.B., 1999. The Latino mortality

paradox: a test of the“ salmon bias” and healthy migrant hypotheses. American Journal of

Public Health 89, 1543–1548.

Alegría, M., Canino, G., Shrout, P., Woo, M., Duan, N., Vila, D., Torres, M., Chen, C., Meng,

X.-L., 2008. Prevalence of mental illness in immigrant and non-immigrant US Latino

groups. American Journal of Psychiatry 165, 359–369.

Alegria, M., Jackson, J.S., Kessler, R.C., Takeuchi, D., 2007a. Collaborative Psychiatric

Epidemiology Surveys (CPES), 2001–2003 [United States]. Computer file ICPSR20240-

v5. Ann Arbor, MI: Institute for Social Research, Survey Research Center [producer].

Alegria, M., Shrout, P.E., Woo, M., Guarnaccia, P., Sribney, W., Vila, D., Polo, A., Cao, Z.,

Mulvaney-Day, N., Torres, M., others, 2007b. Understanding differences in past year

psychiatric disorders for Latinos living in the US. Social Science and Medicine 65, 214–

230.

Alegria, M., Takeuchi, D., Canino, G., Duan, N., Shrout, P., Meng, X.-L., Vega, W., Zane, N.,

Vila, D., Woo, M., others, 2004. Considering context, place and culture: the National

Latino and Asian American Study. International journal of methods in psychiatric

research 13, 208–220.

Armando, M., Nelson, B., Yung, A.R., Ross, M., Birchwood, M., Girardi, P., Nastro, P.F., 2010.

Psychotic-like experiences and correlation with distress and depressive symptoms in a

community sample of adolescents and young adults. Schizophrenia research 119, 258–

265.

Auger, N., Luo, Z.C., Platt, R.W., Daniel, M., 2008. Do mother’s education and foreign born

status interact to influence birth outcomes? Clarifying the epidemiological paradox and

the healthy migrant effect. Journal of epidemiology and community health 62, 402–409.

Beiser, M., Hou, F., Hyman, I., Tousignant, M., 2002. Poverty, family process, and the mental

health of immigrant children in Canada. American Journal of Public Health 92, 220–227.

Bennett, S.A., 1993. Inequalities in risk factors and cardiovascular mortality among Australia’s

immigrants. Australian journal of public health 17, 251–261.

Bhugra, D., 2000. Migration and schizophrenia. Acta Psychiatrica Scandinavica 102, 68–73.

Bhugra, D., 2004. Migration and mental health. Acta Psychiatrica Scandinavica 109, 243–258.

Bhugra, D., Hilwig, M., Hossein, B., Marceau, H., Neehall, J., Leff, J., Mallett, R., Der, G.,

1996. First-contact incidence rates of schizophrenia in Trinidad and one-year follow-up.

The British Journal of Psychiatry 169, 587–592.

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. Bmj 323, 1336.

Bresnahan, M., Begg, M.D., Brown, A., Schaefer, C., Sohler, N., Insel, B., Vella, L., Susser, E.,

2007. Race and risk of schizophrenia in a US birth cohort: another example of health

disparity? International Journal of Epidemiology 36, 751–758.

Bruce Newbold, K., 2005. Self-rated health within the Canadian immigrant population: risk and

the healthy immigrant effect. Social science and medicine 60, 1359–1370.

Bruce Newbold, K., Danforth, J., 2003. Health status and Canada’s immigrant population. Social

science and medicine 57, 1981–1995.

Burnam, M.A., Hough, R.L., Karno, M., Escobar, J.I., Telles, C.A., 1987. Acculturation and

lifetime prevalence of psychiatric disorders among Mexican Americans in Los Angeles.

Journal of health and social behavior 89–102.

Cantor-Graae, E., Pedersen, C.B., McNEIL, T.F., Mortensen, P.B., 2003. Migration as a risk

factor for schizophrenia: a Danish population-based cohort study. The British Journal of

Psychiatry 182, 117–122.

Cantor-Graae, E., Selten, J.-P., 2005. Schizophrenia and migration: a meta-analysis and review.

American Journal of Psychiatry 162, 12–24.

Cohen, C.I., Marino, L., 2013. Racial and ethnic differences in the prevalence of psychotic

symptoms in the general population. Psychiatric Services 64, 1103–1109.

Corcoran, C., Perrin, M., Harlap, S., Deutsch, L., Fennig, S., Manor, O., Nahon, D., Kimhy, D.,

Malaspina, D., Susser, E., 2009. Incidence of schizophrenia among second-generation

immigrants in the Jerusalem Perinatal Cohort. Schizophrenia bulletin 35, 596–602.

Corral, I., Landrine, H., 2008. Acculturation and ethnic-minority health behavior: a test of the

operant model. Health Psychology 27, 737.

Crager, M., Chu, T., Link, B., Rasmussen, A., 2013. Forced Migration and Psychotic Symptoms:

An Analysis of the National Latino and Asian American Study. Journal of Immigrant and

Refugee Studies 11, 299–314.

Das-Munshi, J., Bécares, L., Boydell, J.E., Dewey, M.E., Morgan, C., Stansfeld, S.A., Prince,

M.J., 2012. Ethnic density as a buffer for psychotic experiences: findings from a national

survey (EMPIRIC). The British Journal of Psychiatry 201, 282–290.

Dealberto, M.J., 2007. Why are immigrants at increased risk for psychosis? Vitamin D

insufficiency, epigenetic mechanisms, or both? Medical hypotheses 68, 259–267.

DeVylder, J.E., Oh, H.Y., Corcoran, C.M., Lukens, E.P., 2014. Treatment Seeking and Unmet

Need for Care Among Persons Reporting Psychosis-Like Experiences. Psychiatric

Services.

DeVylder, J.E., Oh, H.Y., Yang, L.H., Cabassa, L.J., Chen, F., Lukens, E.P., 2013. Acculturative

stress and psychotic-like experiences among Asian and Latino immigrants to the United

States. Schizophrenia research 150, 223–228.

Eschbach, K., Ostir, G.V., Patel, K.V., Markides, K.S., Goodwin, J.S., 2004. Neighborhood

context and mortality among older Mexican Americans: is there a barrio advantage?

Journal Information 94.

Fisher, H.L., Caspi, A., Poulton, R., Meier, M.H., Houts, R., Harrington, H., Arseneault, L.,

Moffitt, T.E., 2013. Specificity of childhood psychotic symptoms for predicting

schizophrenia by 38 years of age: a birth cohort study. Psychological medicine 43, 2077–

2086.

Forbes, D., Frisbie, W.P., 1991. Spanish surname and Anglo infant mortality: Differentials over

a half-century. Demography 28, 639–660.

Guendelman, S., Buekens, P., Blondel, B., Kaminski, M., Notzon, F.C., Masuy-Stroobant, G.,

1999. Birth outcomes of immigrant women in the United States, France, and Belgium.

Maternal and child health journal 3, 177–187.

Haro, J.M., Arbabzadeh-Bouchez, S., Brugha, T.S., De Girolamo, G., Guyer, M.E., Jin, R.,

Lepine, J.P., Mazzi, F., Reneses, B., Vilagut, G., others, 2006. Concordance of the

Composite International Diagnostic Interview Version 3.0 (CIDI 3.0) with standardized

clinical assessments in the WHO World Mental Health surveys. International journal of

methods in psychiatric research 15, 167–180.

Harrison, G., Owens, D., Holton, A., Neilson, D., Boot, D., 1988. A prospective study of severe

mental disorder in Afro-Caribbean patients. Psychological medicine 18, 643–657.

Hickling, F.W., Rodgers-Johnson, P., 1995. The incidence of first contact schizophrenia in

Jamaica. The British Journal of Psychiatry 167, 193–196.

Hutchinson, G., Haasen, P.D.C., 2004. Migration and schizophrenia. Social Psychiatry and

Psychiatric Epidemiology 39, 350–357.

Hutchinson, G., Takei, N., Fahy, T.A., Bhugra, D., Gilvarry, C., Moran, P., Mallett, R., Sham, P.,

Leff, J., Murray, R.M., 1996. Morbid risk of schizophrenia in first-degree relatives of

white and African-Caribbean patients with psychosis. The British Journal of Psychiatry

169, 776–780.

Hyman, I., 2004. Setting the stage: reviewing current knowledge on the health of Canadian

immigrants. Can J Public Health 95, 1–8.

Hyman, I., Dussault, G., 1995. The effect of acculturation on low birthweight in immigrant

women. Canadian journal of public health= Revue canadienne de sante publique 87, 158–

162.

Jackson, J.S., Torres, M., Caldwell, C.H., Neighbors, H.W., Nesse, R.M., Taylor, R.J.,

Trierweiler, S.J., Williams, D.R., 2004. The National Survey of American Life: a study of

racial, ethnic and cultural influences on mental disorders and mental health. International

journal of methods in psychiatric research 13, 196–207.

Jasso, G., Massey, D.S., Rosenzweig, M.R., Smith, J.P., 2004. Immigrant health: selectivity and

acculturation. Critical perspectives on racial and ethnic differences in health in late life

227–266.

Johnson, T.P., 2007. Cultural-level influences on substance use and misuse. Substance use and

misuse 42, 305–316.

Kaplan, M.S., Marks, G., 1990. Adverse effects of acculturation: Psychological distress among

Mexican American young adults. Social Science and Medicine 31, 1313–1319.

Kaymaz, N., Drukker, M., Lieb, R., Wittchen, H.-U., Werbeloff, N., Weiser, M., Lataster, T.,

van Os, J., 2012. Do subthreshold psychotic experiences predict clinical outcomes in

unselected non-help-seeking population-based samples? A systematic review and meta-

analysis, enriched with new results. Psychological medicine 42, 2239–2253.

Kessler, R.C., McGonagle, K.A., Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen,

H.-U., Kendler, K.S., 1994. Lifetime and 12-month prevalence of DSM-III-R psychiatric

disorders in the United States: results from the National Comorbidity Survey. Archives of

general psychiatry 51, 8–9.

Kessler, R.C., Merikangas, K.R., 2004. The National Comorbidity Survey Replication (NCS-R):

background and aims. International journal of methods in psychiatric research 13, 60–68.

King, M., Nazroo, J., Weich, S., McKenzie, K., Bhui, K., Karlson, S., Stansfeld, S., Tyrer, P.,

Blanchard, M., Lloyd, K., others, 2005. Psychotic symptoms in the general population of

England. Social psychiatry and psychiatric epidemiology 40, 375–381.

Kirkbride, J.B., Morgan, C., Fearon, P., Dazzan, P., Murray, R.M., Jones, P.B., 2007.

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

Psychological medicine 37, 1413–1425.

Kitagawa, E.M., Hauser, P.M., 1973. Differential mortality in the United States: A study in

socioeconomic epidemiology. Harvard University Press Cambridge, MA.

Ku, L., Matani, S., 2001. Left out: immigrants’ access to health care and insurance. Health

Affairs 20, 247–256.

Landale, N.S., Oropesa, R.S., Llanes, D., Gorman, B.K., 1999. Does Americanization have

adverse effects on health?: stress, health habits, and infant health outcomes among Puerto

Ricans. Social Forces 78, 613–641.

Le, T.N., Kato, T., 2006. The role of peer, parent, and culture in risky sexual behavior for

Cambodian and Lao/Mien adolescents. Journal of adolescent health 38, 288–296.

Lichter, D.T., Johnson, K.M., 2009. Immigrant Gateways and Hispanic Migration to New

Destinations1. International Migration Review 43, 496–518.

Linscott, R.J., Van Os, J., 2013. An updated and conservative systematic review and meta-

analysis of epidemiological evidence on psychotic experiences in children and adults: on

the pathway from proneness to persistence to dimensional expression across mental

disorders. Psychological medicine 43, 1133–1149.

Mahy, G.E., Mallett, R., Leff, J., Bhugra, D., 1999. First-contact incidence rate of schizophrenia

on Barbados. The British Journal of Psychiatry 175, 28–33.

Mak, W.W., Chen, S.X., Wong, E.C., Zane, N.W., 2005. A psychosocial model of stress–distress

relationship among Chinese Americans. Journal of social and clinical psychology 24,

422–444.

Markides, K.S., Coreil, J., 1986. The health of Hispanics in the southwestern United States: an

epidemiologic paradox. Public health reports 101, 253.

Marmot, M.G., Syme, S.L., Kagan, A., Kato, H., Cohen, J.B., Belsky, J., 1975. Epidemiologic

studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and

California: prevalence of coronary and hypertensive heart disease and associated risk

100

factors. American Journal of epidemiology 102, 514–525.

McDonald, J.T., Kennedy, S., 2004. Insights into the “healthy immigrant effect”: health status

and health service use of immigrants to Canada. Social science and medicine 59, 1613–

1627.

McGrath, J., Saha, S., Welham, J., El Saadi, O., MacCauley, C., Chant, D., 2004. A systematic

review of the incidence of schizophrenia: the distribution of rates and the influence of

sex, urbanicity, migrant status and methodology. BMC medicine 2, 13.

Murphy, H.B.M., 1973. Migration and the major mental disorders: a reappraisal. In: Uprooting

and After... Springer, pp. 204–220.

Murphy, J., Shevlin, M., Houston, J., Adamson, G., 2010. A population based analysis of

subclinical psychosis and help-seeking behavior. Schizophrenia bulletin sbq092.

Nair, C., Nargundkar, M., Johansen, H., Strachan, J., 1989. Canadian cardiovascular disease

mortality: first generation immigrants versus Canadian born. Health reports 2, 203–228.

Nasim, A., Corona, R., Belgrave, F., Utsey, S.O., Fallah, N., 2007. Cultural orientation as a

protective factor against tobacco and marijuana smoking for African American young

women. Journal of Youth and Adolescence 36, 503–516.

Newbold, K.B., 2006. Chronic conditions and the healthy immigrant effect: evidence from

Canadian immigrants. Journal of Ethnic and Migration Studies 32, 765–784.

Nguyen, L., Peterson, C., 1993. Depressive symptoms among Vietnamese-American college

students. The Journal of social psychology 133, 65–71.

Nuevo, R., Chatterji, S., Verdes, E., Naidoo, N., Arango, C., Ayuso-Mateos, J.L., 2010. The

continuum of psychotic symptoms in the general population: a cross-national study.

Schizophrenia bulletin sbq099.

101

Oh, H., DeVylder, J.E., Chen, F., 2014. To Treat or Not to Treat: Responding to Psychotic

Experiences. British Journal of Social Work bct199.

Oppedal, B., Røysamb, E., Heyerdahl, S., 2005. Ethnic group, acculturation, and psychiatric

problems in young immigrants. Journal of Child Psychology and Psychiatry 46, 646–660.

Palloni, A., Arias, E., 2004. Paradox lost: explaining the Hispanic adult mortality advantage.

Demography 41, 385–415.

Razum, O., Zeeb, H., Akgün, H.S., Yilmaz, S., 1998. Low overall mortality of Turkish residents

in Germany persists and extends into a second generation: merely a healthy migrant

effect?*. Tropical Medicine and International Health 3, 297–303.

Razum, O., Zeeb, H., Rohrmann, S., 2000. The “healthy migrant effect”–not merely a fallacy of

inaccurate denominator figures. International Journal of Epidemiology 29, 191–192.

Rubalcava, L.N., Teruel, G.M., Thomas, D., Goldman, N., 2008. The healthy migrant effect: new

findings from the Mexican Family Life Survey. Journal Information 98.

Rumbaut, R.G., Weeks, J.R., 1996. Unraveling a public health enigma: Why do immigrants

experience superior perinatal health outcomes? Research in the Sociology of Health Care

13, 335–388.

Saha, S., Chant, D., Welham, J., McGrath, J., 2005. A systematic review of the prevalence of

schizophrenia. PLoS medicine 2, e141.

Schofield, P., Ashworth, M., Jones, R., 2011. Ethnic isolation and psychosis: re-examining the

ethnic density effect. Psychological medicine 41, 1263–1269.

Schwartz, S.J., Pantin, H., Sullivan, S., Prado, G., Szapocznik, J., 2006. Nativity and years in the

receiving culture as markers of acculturation in ethnic enclaves. Journal of Cross-Cultural

Psychology 37, 345–353.

102

Schwartz, S.J., Unger, J.B., Zamboanga, B.L., Szapocznik, J., 2010. Rethinking the concept of

acculturation: implications for theory and research. American Psychologist 65, 237.

Scott, J., Chant, D., Andrews, G., McGRATH, J., 2006. Psychotic-like experiences in the general

community: the correlates of CIDI psychosis screen items in an Australian sample.

Psychological medicine 36, 231–238.

Selten, J.-P., Cantor-Graae, E., 2005. Social defeat: risk factor for schizophrenia? The British

Journal of Psychiatry 187, 101–102.

Selten, J.-P., Cantor-Graae, E., Kahn, R.S., 2007. Migration and schizophrenia. Current Opinion

in Psychiatry 20, 111–115.

Singh, G.K., Hiatt, R.A., 2006. Trends and disparities in socioeconomic and behavioural

characteristics, life expectancy, and cause-specific mortality of native-born and foreign-

born populations in the United States, 1979–2003. International journal of epidemiology

35, 903–919.

Starr, K., 2009. Golden Dreams: California in an Age of Abundance, 1950-1963. Oxford

University Press.

Steiner, N., 2009. International migration and citizenship today. Routledge.

Swerdlow, A.J., 1991. Mortality and cancer incidence in Vietnamese refugees in England and

Wales: a follow-up study. International journal of epidemiology 20, 13–19.

Takayanagi, Y., Spira, A.P., Roth, K.B., Gallo, J.J., Eaton, W.W., Mojtabai, R., 2014. Accuracy

of Reports of Lifetime Mental and Physical Disorders: Results From the Baltimore

Epidemiological Catchment Area Study. JAMA psychiatry 71, 273–280.

Turra, C.M., Elo, I.T., 2008. The impact of salmon bias on the Hispanic mortality advantage:

New evidence from social security data. Population Research and Policy Review 27,

103

515–530.

Unger, J.B., Reynolds, K., Shakib, S., Spruijt-Metz, D., Sun, P., Johnson, C.A., 2004.

Acculturation, physical activity, and fast-food consumption among Asian-American and

Hispanic adolescents. Journal of community health 29, 467–481.

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, 663–668.

Vega, W.A., Amaro, H., 1994. Latino outlook: good health, uncertain prognosis. Annual review

of public health 15, 39–67.

Vega, W.A., Sribney, W.M., Miskimen, T.M., Escobar, J.I., Aguilar-Gaxiola, S., 2006. Putative

psychotic symptoms in the Mexican American population: prevalence and co-occurrence

with psychiatric disorders. The Journal of nervous and mental disease 194, 471–477.

Veling, W., Hoek, H.W., Mackenbach, J.P., 2008a. Perceived discrimination and the risk of

schizophrenia in ethnic minorities. Social psychiatry and psychiatric epidemiology 43,

953–959.

Veling, W., Susser, E., Van Os, J., Mackenbach, J., Selten, J.-P., Hoek, H., 2008b. Ethnic density

of neighborhoods and incidence of psychotic disorders among immigrants. American

Journal of Psychiatry 165, 66–73.

Werbeloff, N., Drukker, M., Dohrenwend, B.P., Levav, I., Yoffe, R., van Os, J., Davidson, M.,

Weiser, M., 2012. Self-reported attenuated psychotic symptoms as forerunners of severe

mental disorders later in life. Archives of General Psychiatry 69, 467–475.

Williams, D.R., Haile, R., Gonzalez, H.M., Neighbors, H., Baser, R., Jackson, J.S., 2007. The

mental health of Black Caribbean immigrants: results from the National Survey of

104

American Life. Journal Information 97.

Williams, R., 1993. Health and length of residence among South Asians in Glasgow: a study

controlling for age. Journal of Public Health 15, 52–60.

Wright, R. O. (2008). Chronology of immigration in the United States. McFarland & Company.

Yoo, H.C., Gee, G.C., Takeuchi, D., 2009. Discrimination and health among Asian American

immigrants: Disentangling racial from language discrimination. Social Science and

Medicine 68, 726–732.

Yung, A.R., Buckby, J.A., Cotton, S.M., Cosgrave, E.M., Killackey, E.J., Stanford, C., Godfrey,

K., McGorry, P.D., 2006. Psychotic-like experiences in nonpsychotic help-seekers:

associations with distress, depression, and disability. Schizophrenia Bulletin 32, 352–359. tions with distress, depression, and disability. Schizophrenia Bulletin, 32(2), 352–359.

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Chapter V: Conclusion

Summary and Discussion of Findings

This dissertation explored the relationship between social defeat and psychotic experiences, focusing on discrimination and immigration as two major themes. In the first paper,

I examined the relationship between everyday discrimination and PE using The National Latino and Asian American Survey and The National Survey of American Life. I found that when compared to individuals who did not report any discrimination, those who reported the highest levels of discrimination were significantly more likely to report both 12-month PE and lifetime

PE, in linear fashion, after adjusting for demographic variables, socioeconomic status, and co- occurring psychological/social problems. This held true for visual and auditory hallucinatory experiences, as well as delusional ideation.

In the second paper, I examined the National Survey of American Life to analyze the effects of nine major discriminatory events on PE, operating under the belief that the major discriminatory events are proxies for structural discrimination. I found that experiencing a greater range of major discriminatory events is associated with an increased risk for lifetime PE, including hallucinations and delusions, after adjusting for demographic variables, socioeconomic status, and co-occurring psychological/social problems. As a count of events, discrimination yielded a significant and strong effect, but disaggregating the events showed that being abused by the police, being denied a loan, and receiving unusually bad service were the only remarkable events. The effects of police abuse were striking in that they remained unaffected by the inclusion of covariates.

In the final study, I examined the National Comorbidity Survey-Replication, The

National Latino and Asian American Survey, and The National Survey of American Life to

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explore the association between immigrant status and PE. I found that an absence of an immigration effect on PE across various ethnic groups and across various geographic areas, after adjusting for demographic variables and socioeconomic status, supporting the idea that the epidemiological paradox pertains to psychosis.

Taken together, these three studies elaborate on the concept of social defeat by depicting a complex association between discrimination and PE. Everyday discrimination at the interpersonal level seems to have clear effects on PE, while this is true only for certain types of major discriminatory events. Contrary to the concept of social defeat, immigrant status has no effect on PE; however, this might reflect a selection phenomenon where healthier individuals tended to immigrate to the US. My findings serve as a starting point for future inquiry, but should bear in mind a number of potential limitations.

Potential Limitations and Future Directions

The potential limitations of my work stem from the limitations of stress research in general, which have been laid out in detail by Monroe (2006). Of note, major event checklists seem to be problematic in that they do not capture subjective appraisals of events (Dohrenwend,

2006). Conceivably an event can be trivial to one person, but catastrophic to another person, thereby having different effects on mental health. Interview-based measures get around this problem by allowing the participant to identify and describe stressful events and express the degree to which the events impacted them. Moreover, the researcher is able to clarify or probe more deeply to discern the nature of the stressful event and its impact on the participant. But interviews are costly and time-consuming, and infeasible for large-scale epidemiological studies.

I investigated the topic of discrimination, which is a complex social determinant of psychosis that can be dissected into many different forms and facets (e.g. individual,

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institutional, structural, cultural; see Harrell, 2011), each deserving of its own investigation linking discrimination to physiological and psychological health outcomes. Research of this nuanced nature can illuminate the intricacies of social defeat.

In my literature review of immigration and psychosis, I hinted at the value of making global comparisons to better understand whether and to what extent associations between discrimination and PE are unique to time and place, and to what extent are they ubiquitous.

Comparisons between countries (e.g. developed versus developing; racially heterogeneous versus racially homogenous; long-standing history of immigration versus recent history of immigration) using consistent and robust measures of discrimination and PE can determine whether there are significant moderating effects of cultural context, and may provide insight that can inform mental health policy.

Implications for social work practice

My findings contribute to the growing body of work that reveals the deleterious effects of discrimination on health, and can inform prevention strategies. For example, discrimination screenings can be administered in various community-based health care and social service settings that serve racial/ethnic populations at risk for schizophrenia. Individuals who rate highly on everyday discrimination or endorse specific discriminatory items (such as police abuse) can be referred to prevention and early intervention programs that provide psychoeducation and guide individuals to resources in the community.

Endorsing PE poses a dilemma in that research is currently ambivalent about whether or not PE warrant clinical treatment (Oh et al., 2014). Conservatively, practitioners ought to employ the least invasive measures first that maximize benefits while minimizing risk (DeVylder, 2014).

Such measures might include mobile applications to monitor experiences and associated distress

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(Ben-Zeev, 2012), family therapy (Seikkula et al., 2011), support groups (Ruddle et al., 2011), omega-3 supplements (Peet & Stokes, 2005), and Cognitive Behavioral Therapy (Morrison et al.,

2014; Turkington et al., 2014). My findings can also motivate community-level programs that foster social solidarity and a sense of belonging, which have been known to buffer the effects of social stressors that lead to psychosis among racial/ethnic minorities (Das-Munshi et al., 2012).

My work is particularly timely given the state of racism in the United States. While we as a society have made great strides toward racial equality since the civil rights movement, we are still struggling to uphold the precedent that the lives of racial and ethnic minorities matter. The recent events of racism, both interpersonal and structural, that occurred during the time this dissertation was written are far too numerous to list exhaustively here, but notable events include: the death of Eric Garner in New York City; the death of Michael Brown in Ferguson,

Missouri; and the death of Walter Scott near North Charleston, South Carolina. Each of these black men was killed at the hands of a police officer; two out of the three police officers were exonerated, while the third awaits trial for murder.

As social workers, we can feel overwhelmed by the breadth of injustice that we must rectify. Much of my dissertation has depicted a story about how this injustice creates risk and vulnerability for oppressed populations. However, I would like to conclude by highlighting the remarkable and paradoxical resilience that racial and ethnic minorities exhibit in the US. Blacks still report fewer mental health problems when compared with whites, and immigrants are healthier than their native-born counterparts. These triumphs challenge existing social stress paradigms and motivate future studies to identify and replicate the qualities that enable humans to endure and thrive despite exposure to adversity.

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Ben-Zeev, D. (2012). Mobile technologies in the study, assessment, and treatment of

schizophrenia. Schizophrenia Bulletin, sbr179.

Das-Munshi, J., Bécares, L., Boydell, J. E., Dewey, M. E., Morgan, C., Stansfeld, S. A., &

Prince, M. J. (2012). Ethnic density as a buffer for psychotic experiences: findings from a

national survey (EMPIRIC). The British Journal of Psychiatry, 201(4), 282–290.

DeVylder, J. (2014). Maximizing Benefits and Minimizing Risks in the Primary Prevention of

Schizophrenia. Social Work, 59(4), 363–365.

Dohrenwend, B. P. (2006). Inventorying stressful life events as risk factors for psychopathology:

Toward resolution of the problem of intracategory variability. Psychological Bulletin,

132(3), 477.

Earl, T. R., Fortuna, L. R., Gao, S., Williams, D. R., Neighbors, H., Takeuchi, D., & Alegría, M.

(2014). An exploration of how psychotic-like symptoms are experienced, endorsed, and

understood from the National Latino and Asian American Study and National Survey of

American Life. Ethnicity & Health, (ahead-of-print), 1–20.

Monroe, S. M. (2008). Modern approaches to conceptualizing and measuring human life stress.

Annu. Rev. Clin. Psychol., 4, 33–52.

Morrison, A. P., Turkington, D., Pyle, M., Spencer, H., Brabban, A., Dunn, G., … others. (2014).

Cognitive therapy for people with schizophrenia spectrum disorders not taking

antipsychotic drugs: a single-blind randomised controlled trial. The Lancet, 383(9926),

1395–1403.

Peet, M., & Stokes, C. (2005). Omega-3 fatty acids in the treatment of psychiatric disorders.

Drugs, 65(8), 1051–1059.

Ruddle, A., Mason, O., & Wykes, T. (2011). A review of hearing voices groups: Evidence and

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mechanisms of change. Clinical Psychology Review, 31(5), 757–766.

Seikkula, J., Alakare, B., & Aaltonen, J. (2011). The comprehensive open-dialogue approach in

Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced

community care. Psychosis, 3(3), 192–204.

Turkington, D., Dudley, R., Warman, D. M., & Beck, A. T. (2014). Cognitive-Behavioral

Therapy for Schizophrenia: A Review. Retrieved from

http://focus.psychiatryonline.org/doi/abs/10.1176/foc.4.2.223

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APPENDICIES

The WHO CIDI 3.0 Psychosis Screen The next questions are about unusual things, like seeing visions or hearing voices. We believe that these things may be quite common, but we don't know for sure because previous research has not done a good job asking about them. So please take your time and think carefully before answering.

The first thing is seeing a vision -- that is, seeing something that other people who were there

could not see. Did you ever see a vision that other people could not see? If yes, then… 1= Yes 0 = No

Visual Did this ever happen when you were not dreaming, not half-asleep, and not under the influence of

alcohol or drugs? Hallucination

The second thing is hearing voices that other people could not hear. I don't mean having good

hearing, but rather hearing things that other people said did not exist, like strange voices coming from inside your head talking to you or about you, or voices coming out of the air when there was 1= Yes no one around. Did you ever hear voices? If yes, then… 0 = No

Auditory Did this ever happen when you were not dreaming, not half-asleep, and not under the influence of Hallucination alcohol or drugs? The third thing is really two. One is believing that some mysterious force was inserting many different strange thoughts -- that were definitely not your own thoughts - directly into your head by means of x-rays or laser beams or other methods. The other is believing that your own thoughts were being stolen out of your mind by some strange force. Did you ever have either of these mind 1= Yes control experiences? If yes, then… 0 = No Did this ever happen when you were not dreaming, not half-asleep, and not under the influence of alcohol or drugs?

The fourth unusual thing is feeling that your mind was being taken over by strange forces with

laser beams or other methods that were making you do things you did not choose to do. Did you ever have a time when you felt that your mind was being taken over by strange forces? If yes, 1= Yes

Ideation then… 0 = No

Did this ever happen when you were not dreaming, not half-asleep, and not under the influence of alcohol or drugs? The fifth thing is believing that some strange force was trying to communicate directly with you by

Delusional sending special signs or signals that you could understand but that no one else could understand. Sometimes this happens by special signs coming through the radio or television. Did you ever 1= Yes experience these kinds of attempts at communication from strange forces? If yes, then… 0 = No Did this ever happen when you were not dreaming, not half-asleep, and not under the influence of alcohol or drugs? Sixth, did you ever believe that there was an unjust plot going on to harm you or to have people follow you that your family and friends did not believe was true? If yes, then… 1= Yes Did this ever happen when you were not dreaming, not half-asleep, and not under the influence of 0 = No

alcohol or drugs?

[(Has/Have) (this/either of these things/any of these things)] happened to you at any time in the 1= Yes month

- past 12 months? 0 = No 12

Respondents who reported any one of these experiences outside of the context of sleep or

substance use were coded as having a positive endorsement of PE.

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Everyday Discrimination Scale

In your day-to-day life how often have any of the following things happened to you? Would you say almost everyday, at least once a week, a few times a month, a few times a year, less than once a year?

1. You are treated with less courtesy than other people.

2. You are treated with less respect than other people. Respondents rated the 3. You receive poorer service than other people at restaurants or stores. frequency of each of the 9 items using the following 4. People act as if they think you are not smart. options:

5. People act as if they are afraid of you. 0 = no discrimination 1 = less than once a year 6. People act as if they think you are dishonest. 2 = a few times a year 3 = a few times a month 7. People act as if you are not as good as they are. 4 = at least once a week 5 = almost every day 8. You are called names or insulted.

9. You are threatened or harassed.

Major Discriminatory Events In the following questions, we are interested in the way other people have treated you or your beliefs about how other people have treated you. Can you tell me if any of the following has ever happened to you: At any time in your life, have you ever… 1. Been unfairly fired?

2. For unfair reasons, have you ever not been hired for a job?

3. Have you ever been unfairly denied a promotion? 4. Have you ever been unfairly stopped, searched, questioned, physically threatened or abused by the police? Respondents answered yes (1) 5. Have you ever been unfairly discouraged by a teacher or advisor from continuing or no (0) to the lifetime your education? occurrence of each of these 6. Have you ever been unfairly prevented from moving into a neighborhood because nine major discriminatory the landlord or a realtor refused to sell or rent you a house or apartment? events. 7. Have you ever moved into a neighborhood where neighbors made life difficult for you or your family? 8. Have you ever been unfairly denied a bank loan? 9. Have you ever received service from someone such as a plumber or car mechanic that was worse than what other people get?

Immigration Country in which you were born US born = 0; Foreign born = 1 Age at Immigration (years) US born, >12, 13-17, 18-34, 35+ Number of Years in US US born, <5, 5-10, 11-20, 20+ # parents born in U.S. Foreign born (first generation); 0 or 1 (second generation), 2 (third or more)

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Covariates Age (years) Age was a continuous variable ranging from 18 to 99. The variable was coded into four categories: 18-29 (reference), 30-44, 45-59, 60+ Gender Female = 1, Male = 0 Income-to-poverty ratio Income-to-poverty ratio was a continuous variable ranging from 0-17, which was coded into three categories: 0 (poor), 1-2, 3+ (nonpoor -reference) Education (years) Education was coded into four categories: 0-11 (less than high school diploma - reference), 12 (high school graduate), 13-15 (some college), 16+ (college and beyond) Race Race was coded into four dummy variables: White, Asian, Hispanic, Black Caribbean, and African American. In some analyses, ethnicity was further differentiated into sub-categories: Chinese, Vietnamese, Filipino, Other Asian, Mexican, Cuban, Puerto Rican, Other Hispanic, Black Caribbean. Region Region was coded into four dummy variables: Northeast, Midwest, South, and West (reference) Substance Use Substance use was coded as a dichotomous variable indicating the lifetime presence of any of the following: alcohol abuse, alcohol dependence, drug abuse, or drug dependence PTSD PTSD was coded as a dichotomous variable indicating a lifetime endorsement Social Interaction Social Interaction was measured using the WHODAS and ranged from 0 to 100, with 0 signifying no impairment. This was coded dichotomously 1-100 = 1, 0 = 0

Self-reported Schizophrenia Diagnosis 0 = No Did you ever talk to a doctor or mental health 1 = Yes professional for help in dealing with For the purposes of sensitivity analyses, individuals Schizophrenia/Psychosis? who endorsed this item were excluded.

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