Incidence of first contact psychosis in Sao Paulo, Brazil.

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BackgroundBackground Little isknown abouttheLittle isknown aboutthe
incidence of first-episode psychosis inincidence of first-episode psychosis in
urban centres of low- ormiddle-incomeurban centres of low- ormiddle-income
countries.countries.
AimsAims To estimate the incidence ofTo estimate the incidence of
psychosis in Sao Paulo, a largemetropolispsychosis in Sa‹ o Paulo, a largemetropolis
of Brazil.of Brazil.
MethodMethod Prospective surveyof first-Prospective surveyof first-
episode psychosis amongresidents agedepisode psychosis amongresidents aged
18^64 years resident in a defined area of18^64 years resident in a defined area of
Sao Paulo, over a 30-monthperiod (JulySa‹ o Paulo, over a 30-month period (July
2002^December 2004).Assessments2002^December 2004).Assessments
were carried outwiththe SCID^I, andwere carried outwiththe SCID^I, and
diagnosesgiven according to DSM^IVdiagnosesgiven according to DSM^IV
criteria.Population atriskwas drawn fromcriteria.Population atriskwas drawn from
the 2000 Census data.the 2000 Census data.
ResultsResults Therewere 367 first-episodeTherewere 367 first-episode
cases identified (51% women), and almostcases identified (51% women), and almost
40% fulfilled criteria for schizophrenia or40% fulfilled criteria for schizophrenia or
schizophreniformdisorder.The incidenceschizophreniformdisorder.The incidence
rate for anypsychosiswas15.8/100 000rate for anypsychosiswas15.8/100 000
person-years at risk (95% CI14.3^17.6).person-years at risk (95% CI14.3^17.6).
Incidence of non-affective psychoseswasIncidence of non-affective psychoseswas
higher among youngermales.higher among youngermales.
ConclusionsConclusions Incidence of psychosis inIncidence of psychosis in
Sao Paulowas lower than expected for aSa‹ o Paulowas lower than expected for a
largemetropolis.largemetropolis.
Declaration of interestDeclaration of interest None.None.
Fundingdetailed in Acknowledgements.Fundingdetailed in Acknowledgements.
Studies on the incidence of schizophreniaStudies on the incidence of schizophrenia
have shown wide variation in theirhave shown wide variation in their
estimates, variations which cannot beestimates, variations which cannot be
attributed exclusively to methodologicalattributed exclusively to methodological
differences between studies (McGrathdifferences between studies (McGrath etet
alal, 2004). For example, recent investiga-, 2004). For example, recent investiga-
tions have consistently shown higher risktions have consistently shown higher risk
of psychosis for individuals brought up inof psychosis for individuals brought up in
urban centres, as compared to those fromurban centres, as compared to those from
rural areas (Krabbendam & van Os,rural areas (Krabbendam & van Os,
2005). Other studies have demonstrated2005). Other studies have demonstrated
high rates in migrants, particularly Blackhigh rates in migrants, particularly Black
migrants to countries with predominantlymigrants to countries with predominantly
White populations (Cantor-Graae &White populations (Cantor-Graae &
Selten, 2005). Studies on the incidence ofSelten, 2005). Studies on the incidence of
affective psychoses are much less frequent.affective psychoses are much less frequent.
However, the vast majority of these studiesHowever, the vast majority of these studies
on the epidemiology of psychosis have beenon the epidemiology of psychosis have been
carried out in Europe or North America.carried out in Europe or North America.
In Brazil, as in many low- and middle-In Brazil, as in many low- and middle-
income countries, marked demographicincome countries, marked demographic
changes have taken place in recent decades,changes have taken place in recent decades,
with population ageing and disorganisedwith population ageing and disorganised
urbanisation (Cohen, 2003). These changesurbanisation (Cohen, 2003). These changes
may have had an impact on the incidence ofmay have had an impact on the incidence of
psychosis, since there has been an increasepsychosis, since there has been an increase
in the adult population at risk and in pos-in the adult population at risk and in pos-
sible risk factors, such as migration, as wellsible risk factors, such as migration, as well
as higher exposure to viruses and to adverseas higher exposure to viruses and to adverse
life events. There is a lack of empirical datalife events. There is a lack of empirical data
on the incidence of schizophrenia and affec-on the incidence of schizophrenia and affec-
tive psychoses in such settings. The presenttive psychoses in such settings. The present
study aimed to estimate incidence rates ofstudy aimed to estimate incidence rates of
first-contact psychosis in Sao Paulo, thefirst-contact psychosis in Sa˜o Paulo, the
largest city in Brazil.largest city in Brazil.
METHODMETHOD
The settingThe setting
Greater Sao Paulo is one of the largest con-Greater Sa˜o Paulo is one of the largest con-
urbations in the world, with a populationurbations in the world, with a population
of 19 million inhabitants, of which 11 mil-of 19 million inhabitants, of which 11 mil-
lion live in the city of Sao Paulo (Prefeituralion live in the city of Sa˜o Paulo (Prefeitura
do Municıpio de Sao Paulo, 2006). Saodo Municı´pio de Sa˜o Paulo, 2006). Sa˜o
Paulo is the wealthiest city of Brazil, con-Paulo is the wealthiest city of Brazil, con-
centrating 10% of the national gross do-centrating 10% of the national gross do-
mestic product. As a consequence, it hasmestic product. As a consequence, it has
attracted a large number of migrants fromattracted a large number of migrants from
poorer areas of the country, and social in-poorer areas of the country, and social in-
equalities are strong. The average Humanequalities are strong. The average Human
Development Index is 0.81, ranking SaoDevelopment Index is 0.81, ranking Sa˜o
Paulo as the 63rd best among 5507 citiesPaulo as the 63rd best among 5507 cities
and towns of Brazil. Infant mortality rateand towns of Brazil. Infant mortality rate
is 15 per 1000, but varies across city areas.is 15 per 1000, but varies across city areas.
Almost all inhabitants have piped waterAlmost all inhabitants have piped water
and rubbish collected, but nearly 1.2 mil-and rubbish collected, but nearly 1.2 mil-
lion people live in slums termed ‘favelas’,lion people live in slums termed ‘favelas’,
and 10% of heads of households do notand 10% of heads of households do not
have any income of their own.have any income of their own.
Mental healthcare in Sao Paulo is pro-Mental healthcare in Sa˜o Paulo is pro-
vided mainly by the public sector, and avided mainly by the public sector, and a
small proportion of the population receivessmall proportion of the population receives
mental healthcare from the private sector.mental healthcare from the private sector.
Mental healthcare in the public sector isMental healthcare in the public sector is
partially organised on a catchment-area ba-partially organised on a catchment-area ba-
sis. Emergency 24-h psychiatric services cansis. Emergency 24-h psychiatric services can
be sought by anyone who needs immediatebe sought by anyone who needs immediate
attention, regardless of where they live. In-attention, regardless of where they live. In-
patient care is provided by some publicpatient care is provided by some public
psychiatric hospitals and by private hospi-psychiatric hospitals and by private hospi-
tals that offer psychiatric beds to the publictals that offer psychiatric beds to the public
sector on a fee-for-service basis. There is asector on a fee-for-service basis. There is a
central registry service that controls allcentral registry service that controls all
admissions to psychiatric in-patient careadmissions to psychiatricin-patient care
paid for by the public sector in the city, ex-paid for by the public sector in the city, ex-
cept for a few beds in some public generalcept for a few beds in some public general
hospitals with psychiatric in-patient units.hospitals with psychiatric in-patient units.
For individuals suffering from psychosis,For individuals suffering from psychosis,
mental healthcare centres offer out-patientmental healthcare centres offer out-patient
appointments with psychiatrists, and mayappointments with psychiatrists, and may
deliver typical antipsychotic medication. Adeliver typical antipsychotic medication. A
small proportion of patients may havesmall proportion of patients may have
access to psychotherapy, occupational ther-access to psychotherapy, occupational ther-
apy, social support or day-hospital care. Aapy, social support or day-hospital care. A
few primary care centres that have mentalfew primary care centres that have mental
health professionals may offer care tohealth professionals may offer care to
adults with psychotic disorders. Privateadults with psychotic disorders. Private
mental healthcare includes both exclusivelymental healthcare includes both exclusively
private care, where all expenses are paid forprivate care, where all expenses are paid for
by the client, and care provided by health-by the client, and care provided by health-
care plans, where clients can only usecare plans, where clients can only use
services specified by the healthcare planservices specified by the healthcare plan
company. About 40% of the populationcompany. About 40% of the population
are covered by private healthcare plans,are covered by private healthcare plans,
and seek healthcare in private clinics andand seek healthcare in private clinics and
hospitals. However, until recently suchhospitals. However, until recently such
plans did not cover psychiatric care. Fullyplans did not cover psychiatric care. Fully
paid in-patient psychiatric care is availablepaid in-patient psychiatric care is available
in a small number of clinics and privatein a small number of clinics and private
hospitals. There are hundreds of psychia-hospitals. There are hundreds of psychia-
trists in the city who offer private consulta-trists in the city who offer private consulta-
tions, with a wide range of fees.tions, with a wide range of fees.
The area defined for the study was com-The area defined for the study was com-
posed of 21 administrative districts, in theposed of 21 administrative districts, in the
central, western and northern regions ofcentral, western and northern regions of
the city, with a total population ofthe city, with a total population of
1 382 861 inhabitants in the year 20001 382 861 inhabitants in the year 2000
(Prefeitura do Municıpio de Sao Paulo,(Prefeitura do Municı´pio de Sa˜o Paulo,
s10 2s10 2
BR IT I SH JOURNAL OF P SYCHIATRYBR I T I SH JOURNAL OF P SYCHIATRY ( 2 0 0 7 ) , 1 9 1 ( s u p p l . 51 ) , s1 0 2 ^ s1 0 6 . d o i : 1 0 . 11 9 2 / b j p .1 9 1 . 5 1 . s1 0 2( 2 0 0 7 ) , 1 9 1 ( s u pp l . 5 1) , s1 0 2 ^ s1 0 6 . d o i : 1 0 .11 9 2 / b jp .1 9 1 . 51 . s1 0 2
Incidence of first-contact psychosis in Sao Paulo,Incidence of first-contact psychosis in Sa‹ o Paulo,
BrazilBrazil
PAULO R. MENEZES, MARCIA SCAZUFCA, GERALDO BUSATTO,PAULO R. MENEZES, MARCIA SCAZUFCA, GERALDO BUSATTO,
LETICIA M. S. COUTINHO, PHILIP K. MLETI¤ CIA M. S. COUTINHO, PHILIP K. MccGUIREGUIRE andand ROBIN M. MURRAYROBIN M. MURRAY
AUTHOR’S PROOFAUTHOR’S PROOF
F IRST- CONTACT PSYCHOS IS IN SAO PAULO, BR AZILF IRS T- CONTACT P SYCHOS IS IN SA‹ O PAULO, BRAZIL
2006). This area includes residential middle-2006). This area includes residential middle-
class regions, deprived inner-city areas,class regions, deprived inner-city areas,
working-class residential regions, and areasworking-class residential regions, and areas
of ‘favelas’. Mental health services thatof ‘favelas’. Mental health services that
offer care for the public sector in the areaoffer care for the public sector in the area
include five 24-h emergency services, sixinclude five 24-h emergency services, six
mental health centres, four in-patient unitsmental health centres, four in-patient units
in public hospitals, and five primary carein public hospitals, and five primary care
centres with mental health professionals.centres with mental health professionals.
There are three teaching hospitals, two ofThere are three teaching hospitals, two of
them from public universities, located inthem from public universities, located in
the area of the study. These hospitals havethe area of the study. These hospitals have
large psychiatric services, and access to carelarge psychiatric services, and access to care
in these services does not follow geographi-in these services does not follow geographi-
cal catchment-area restrictions.cal catchment-area restrictions.
Case identificationCase identification
and ascertainmentand ascertainment
All mental health services, public or pri-All mental health services, public or pri-
vate, from which individuals living in thevate, from which individuals living in the
area defined might seek help for a psychoticarea defined might seek help for a psychotic
episode, were screened to identify all pos-episode, were screened to identify all pos-
sible cases of first-contact psychosis. Thissible cases of first-contact psychosis. This
included the services listed above, plus theincluded the services listed above, plus the
central registry service for psychiatric in-central registry service for psychiatric in-
patient admissions paid for by the publicpatient admissions paid for by the public
sector, all private psychiatric hospitals andsector, all private psychiatric hospitals and
clinics in the city of Sao Paulo, and twoclinics in the city of Sa˜o Paulo, and two
psychiatric services from private healthcarepsychiatric services from private healthcare
plans. Over 300 psychiatrists who workplans. Over 300 psychiatrists who work
privately, whose names and contacts wereprivately, whose names and contacts were
drawn from the Brazilian Psychiatric Asso-drawn from the Brazilian Psychiatric Asso-
ciation list, were contacted by post and byciation list, were contacted by post and by
phone and asked to say whether they hadphone and asked to say whether they had
seen first-contact patients who lived in theseen first-contact patients who lived in the
area defined for the study during the periodarea defined for the study during the period
specified below. Medical records of eachspecified below. Medical records of each
service were browsed on a regular basis.service were browsed on a regular basis.
Contact details of individuals with any sug-Contact details of individuals with any sug-
gestion of a consultation or admission duegestion of a consultation or admission due
to psychotic symptoms were collected,to psychotic symptoms were collected,
because quite often it was not possible tobecause quite often it was not possible to
establish whether it was a first contact orestablish whether it was a first contact or
not from the medical records. Confirmationnot from the medical records. Confirmation
of first-contact had then to be made byof first-contact had then to be made by
phone or home visit.phone or home visit.
Eligible individuals were all adults agedEligible individuals were all adults aged
18–64 years, resident in the defined geogra-18–64 years, resident in the defined geogra-
phical area of Sao Paulo for at least 6phical area of Sa˜o Paulo for at least 6
months, who had a first contact with anymonths, who had a first contact with any
mental health service due to a psychoticmental health service due to a psychotic
episode between 1 July 2002 and 31episode between 1 July 2002 and 31December 2004. Participants had to meetDecember 2004. Participants had to meet
DSM–IV criteria (American PsychiatricDSM–IV criteria (American Psychiatric
Association, 1994)Association, 1994) for psychotic disorderfor psychotic disorder
(295.10–295.90; 297.1; 298.8; 298.9;(295.10–295.90; 297.1; 298.8; 298.9;
296.0; 296.4; 296.24).296.0; 296.4; 296.24).
DSM–IV diagnoses were obtained forDSM–IV diagnoses were obtained for
those who agreed to be interviewed, usingthose who agreed to be interviewed, using
the Structured Clinical Interview for thethe Structured Clinical Interview for the
DSM–IV Axis I DisordersDSM–IV Axis I Disorders (SCID–I; Spitzer(SCID–I; Spitzer
et alet al, 1992). For those who refused a direct, 1992). For those who refused a direct
assessment or for those who could not beassessment or for those who could not be
directly contacted for other reasons,directly contacted for other reasons,
DSM–IV diagnoses were made based onDSM–IV diagnoses were made based on
information gathered from case notes andinformation gathered from case notes and
informants, wherever possible. Assessmentsinformants, wherever possible. Assessments
were carried out as close as possible to thewere carried out as close as possible to the
identification of each case in the mentalidentification of each case in the mental
health service. Interviews with participantshealth service. Interviews with participants
took place at participants’ homes, and weretook place at participants’ homes, and were
carried out by mental health professionalscarried out by mental health professionals
trained in the use of the standardised assess-trained in the use of the standardised assess-
ments. Training of interviewers includedments. Training of interviewers included
sessions for discussion of all standardisedsessions for discussion of all standardised
assessment schedules used in the study,assessment schedules used in the study,
and interview of patients with psychosisand interview of patients with psychosis
by each interviewer, watched by all remain-by each interviewer, watched by all remain-
ing interviewers and coordinators of theing interviewers and coordinators of the
study, followed by discussion. There wasstudy, followed by discussion. There was
constant supervision of interviewers duringconstant supervision of interviewers during
the study, with discussion of difficulties andthe study, with discussion of difficulties and
doubts in any of the schedules of the studydoubts in any of the schedules of the study
protocol. Written informed consent wasprotocol. Written informed consent was
obtained from all participants.obtained from all participants.
A leakage study was also carried out, inA leakage study was also carried out, in
order to identify cases missed throughoutorder to identify cases missed throughout
the study period, and included surveillancethe study period, and included surveillance
of cases who had a first contact duringof cases who had a first contact during
the period of the study but were only foundthe period of the study but were only found
at a later date by the research team and re-at a later date by the research team and re-
view of casenotes of services not routinelyview of casenotes of services not routinely
visited by the research team.visited by the research team.
AnalysisAnalysis
The total number of person-years at riskThe total number of person-years at risk
was calculated using the number of residentwas calculated using the number of resident
individuals aged 18–64 years living in theindividuals aged 18–64 years living in the
area defined for the study (926 081),area defined for the study (926 081),
according to data from the 2000 Censusaccording to data from the 2000 Census
of the Brazilian population, multiplied byof the Brazilian population, multiplied by
2.5, to give the population at risk over the2.5, to give the population at risk over the
30-month period of inclusion of cases.30-month period of inclusion of cases.
Overall, non-standardised incidence ratesOverall, non-standardised incidence rates
were estimated for first-contact psychosiswere estimated for first-contact psychosis
(all diagnostic categories above), non-(all diagnostic categories above), non-
affective psychoses (DSM–IV codesaffective psychoses (DSM–IV codes
295.10–295.90; 297.1; 298.8; 298.9) and295.10–295.90; 297.1; 298.8; 298.9) and
affective psychoses (DSM–IV codes 296.0;affective psychoses (DSM–IV codes 296.0;
296.4; 296.24). Respective binomial exact296.4; 296.24). Respective binomial exact
95% confidence intervals were calculated.95% confidence intervals were calculated.
Age- and gender-specific incidence ratesAge- and gender-specific incidence rates
were also estimated, with 95% confidencewere also estimated, with 95% confidence
intervals.intervals.
RESULTSRESULTS
There were 172 participants who fulfilledThere were 172 participants who fulfilled
criteria for first-contact psychosis andcriteria for first-contact psychosis and
agreed to be included in the study. Aagreed to be included in the study. A
further 60 individuals were identified asfurther 60 individuals were identified as
first-contact cases but refused to be inter-first-contact cases but refused to be inter-
viewed, and another 135 cases were foundviewed, and another 135 cases were found
through the leakage study. The types of ser-through the leakage study. The types of ser-
vice most frequently sought were the 24-hvice most frequently sought were the 24-h
emergency services, where 67.3% of theemergency services, where 67.3% of the
cases had their first contact, followed bycases had their first contact, followed by
in-patient services (16.3%) and mentalin-patient services (16.3%) and mental
health centres with day care (10.3%).health centres with day care (10.3%).
There were 187 women participantsThere were 187 women participants
(51.0%). One hundred and forty-four(51.0%). One hundred and forty-four
(39.2%) participants fulfilled diagnostic(39.2%) participants fulfilled diagnostic
criteria for schizophrenia or schizophreni-criteria for schizophrenia or schizophreni-
form disorder, 88 (24.0%) for other non-form disorder, 88 (24.0%) for other non-
affective psychoses (mostly brief psychoticaffective psychoses (mostly brief psychotic
disorder and non-specified psychotic dis-disorder and non-specified psychotic dis-
order), 85 (23.2%) fulfilled criteria fororder), 85 (23.2%) fulfilled criteria for
bipolar disorder and 50 (13.6%) forbipolar disorder and 50 (13.6%) for
depression with psychotic symptoms.depression with psychotic symptoms.
The mean age at first contact for anyThe mean age at first contact for any
psychosis was 32.9 years (95%CI 31.7–psychosis was 32.9 years (95%CI 31.7–
34.1), and the median age was 30.0 years34.1), and the median age was 30.0 years
(Table 1). The average age at first contact(Table 1). The average age at first contact
for men was younger than for women,for men was younger than for women,
and the distribution of age at first contactand the distribution of age at first contact
was more positively skewed for men thanwas more positively skewed for men than
for women. Similar patterns of skewnessfor women. Similar patterns of skewness
were observed for both non-affective andwere observed for both non-affective and
affective psychoses. Men showed meanaffective psychoses. Men showed mean
and median ages at first contact for non-and median ages at first contact for non-
affective psychoses 4–5 years younger thanaffective psychoses 4–5 years younger than
for affective psychoses, whereas for womenfor affective psychoses, whereas for women
there were almost no differences betweenthere were almost no differences between
non-affective and affective psychoses.non-affectiveand affective psychoses.
The unadjusted rate for first-contactThe unadjusted rate for first-contact
psychosis was 15.8 per 100 000 person-psychosis was 15.8 per 100 000 person-
years at risk (Table 2). Rates for non-years at risk (Table 2). Rates for non-
affective and affective psychoses wereaffective and affective psychoses were
10.1 per 100 000 and 5.8 per 100 000,10.1 per 100 000 and 5.8 per 100 000,
respectively. First-contact psychosis ratesrespectively. First-contact psychosis rates
declined with increasing age; this wasdeclined with increasing age; this was
mostly due to rates of non-affective psy-mostly due to rates of non-affective psy-
choses among the male population, whichchoses among the male population, which
showed the highest rates in younger ageshowed the highest rates in younger age
groups followed by a sharp decline in oldergroups followed by a sharp decline in older
age groups (Figs. 1 and 2).age groups (Figs. 1 and 2).
DISCUSSIONDISCUSSION
This is the first study to estimate the inci-This is the first study to estimate the inci-
dence of first-episode psychosis in a largedence of first-episode psychosis in a large
metropolis in Brazil. The rate of first-metropolis in Brazil. The rate of first-
episode psychosis (15.8 per 100 000) wasepisode psychosis (15.8 per 100 000) was
lower than expected for a large metropolis.lower than expected for a large metropolis.
For non-affective psychosis, the present rateFor non-affective psychosis, the present rate
is in the lower quartile of incidence esti-is in the lower quartile of incidence esti-
mates found in several studies in differentmates found in several studies in different
settings (McGrathsettings (McGrath et alet al, 2004). Incidence, 2004). Incidence
s10 3s10 3
AUTHOR’S PROOFAUTHOR’S PROOF
MENEZES ET ALMENEZES ET AL
rates of schizophrenia for each participantrates of schizophrenia for each participant
centre in the World Health Organizationcentre in the World Health Organization
(WHO) Ten-Country Study (Jablensky(WHO) Ten-Country Study (Jablensky etet
alal, 1992) and for three studies in Caribbean, 1992) and for three studies in Caribbean
countries (Hickling & Rodgers-Johnson,countries (Hickling & Rodgers-Johnson,
1995; Bhugra1995; Bhugra et alet al, 1996; Mahy, 1996; Mahy et alet al,,
1999), calculated using CATEGO S+ and1999), calculated using CATEGO S+ and
SPO diagnoses, varied from 9 to 35 perSPO diagnoses, varied from 9 to 35 per
100 000. Reanalysis of longitudinal data100 000. Reanalysis of longitudinal data
from two centres in the WHO Ten-Countryfrom two centres in the WHO Ten-Country
Study generated estimates based on ICD–10Study generated estimates based on ICD–10
criteria for F–20 schizophrenia, which var-criteria for F–20 schizophrenia, which var-
ied from 14 per 100 000 in Nottingham toied from 14 per 100 000 in Nottingham to
42 per 100 000 in rural Chadigarh (Bresna-42 per 100 000 in rural Chadigarh (Bresna-
hanhan et alet al, 2003). In the ÆSOP study (Kirk-, 2003). In the ÆSOP study (Kirk-
bridebride et alet al, 2006), carried out in three, 2006), carried out in three
centres of the UK (London, Nottinghamcentres of the UK (London, Nottingham
and Bristol), incidence rates for all first-and Bristol), incidence rates for all first-
contact psychoses, non-affective and af-contact psychoses, non-affective and af-
fective psychoses were higher than in thefective psychoses were higher than in the
present study. This was mostly due to muchpresent study. This was mostly due to much
higher rates for non-affective and affectivehigher rates for non-affective and affective
psychoses in London, rates from Notting-psychoses in London, rates from Notting-
ham and Bristol being similar to those re-ham and Bristol being similar to those re-
ported in the present study.ported in the present study. For affectiveFor affective
psychosis, comparison is more difficult,psychosis, comparison is more difficult,
since most studies did not estimate ratessince most studies did not estimate rates
for bipolar disorder and depressive psycho-for bipolar disorder and depressive psycho-
sis together. Taking that into account, thesis together. Taking that into account, the
present figures for the incidence of affectivepresent figures for the incidence of affective
psychoses are similar to those from thepsychoses are similar to those from the
ÆSOP study (LloydÆSOP study (Lloyd et alet al, 2005; Kirkbride, 2005; Kirkbride
et alet al, 2006)., 2006). Rates were higher for menRates were higher for men
than for women in our study, followingthan for women in our study, following
the pattern observed in a systematic reviewthe pattern observed in a systematic review
of studies on the incidence of schizophreniaof studies on the incidence of schizophrenia
(McGrath(McGrath et alet al, 2004), and in the studies on, 2004), and in the studies on
the incidence of psychosis in the UK (Kirk-the incidence of psychosis in the UK (Kirk-
bridebride et alet al, 2006) and rural Ireland (Scully, 2006) and rural Ireland (Scully
et alet al, 2002). This was mostly due to higher, 2002). This was mostly due to higher
incidence of non-affective psychoses amongincidence of non-affective psychoses among
younger men, whereas rates for affectiveyounger men, whereas rates for affective
psychoses were similar for both genders.psychoses were similar for both genders.
Age at first contact also followed pat-Age at first contact also followed pat-
terns observed previously (van Osterns observed previously (van Os et alet al,,
2000; Boydell2000; Boydell et alet al, 2001; Svedberg, 2001; Svedberg et alet al,,
2001; Scully2001; Scully et alet al, 2002; Welham, 2002; Welham et alet al,,
2004; Kirkbride2004; Kirkbride et alet al, 2006). More than, 2006). More than
60% of the cases had their first contact be-60% of the cases had their first contact be-
fore the age 35, confirming that psychosis isfore the age 35, confirming that psychosis is
more frequent in young adults, but a pro-more frequent in young adults, but a pro-
portion of cases can occur at older ages.portion of cases can occur at older ages.
Men had younger mean and median agesMen had younger mean and median ages
at first contact than women for both affec-at first contact than women for both affec-
tive and non-affective psychoses, a findingtive and non-affective psychoses, a finding
also consistent with results from somealso consistent with results from some
recent studies carried out in high-incomerecent studies carried out in high-income
countries (Svedbergcountries (Svedberg et alet al, 2001; Scully, 2001; Scully etet
alal, 2002; Kirkbride, 2002; Kirkbride et alet al, 2006). However,, 2006). However,
comparison of mean or median age at firstcomparison of mean or median age at first
contact between studies is not straightfor-contact between studies is not straightfor-
ward, since there is variation in the ageward, since there is variation in the age
range criterion used in each study. Somerange criterion used in each study. Some
studies have used the age range 15–45 orstudies have used the age range 15–45 or
15–54 years, which will influence their15–54 years, which will influence their
samples towards younger age means,samples towards younger age means,
whereas those that have wider age ranges,whereas those that have wider age ranges,
particularly for the upper limit, will tendparticularly for the upper limit, will tend
to find older sample means. Comparisonto find older sample means. Comparison
of age- and gender-specific incidence ratesof age- and gender-specific incidence rates
is less subject to such methodologicalis less subject to such methodological
issues. However, few studies yielded age-issues. However, few studies yielded age-and sex-specific incidence rates for bothand sex-specific incidence rates for both
affective and non-affective psychoses,affective and non-affective psychoses,
making comparison of results limited.making comparison of results limited.
Age- and gender-specific rates from theAge- and gender-specific rates from the
present study are lower than those foundpresent study are lower than those found
in the UK (Kirkbridein the UK (Kirkbride et alet al, 2006), but rates, 2006), but rates
in that study were influenced upwards byin that study were influenced upwards by
the uncommonly high rates found in Souththe uncommonly high rates found in South
London. A recent study carried out inLondon. A recent study carried out in
Queensland, Australia (WelhamQueensland, Australia (Welham et alet al,,
2004) also estimated age- and gender-specific2004) also estimated age- and gender-specific
incidence rates for affective and non-affectiveincidence rates for affective and non-affective
psychoses, and results from both studies arepsychoses, and results from both studies are
remarkably similar.remarkably similar.
Limitations and implicationsLimitations and implications
The incidence rate of first-contact psychosisThe incidence rate of first-contact psychosis
may have been underestimated. It is pos-may have been underestimated. It is pos-
sible that a small proportion of first-contactsible that a small proportion of first-contact
s10 4s10 4
AUTHOR’S PROOFAUTHOR’S PROOF
Table1Table1 Mean andmedian ages at first contact for any psychosis, non-affective and affective psychosesMean andmedian ages at first contact for any psychosis, non-affective and affective psychoses
by genderby gender
WomenWomen
((nn¼187)187)
MenMen
((nn¼180)180)
Total sampleTotal sample
((nn¼367)367)
mean (s.d.)mean (s.d.) medianmedian mean (s.d.)mean (s.d.) medianmedian mean (s.d.)mean (s.d.) medianmedian
AnypsychosisAnypsychosis 35.7 (11.8)35.7 (11.8) 34.034.0 30.0 (10.0)30.0 (10.0) 26.526.5 32.9 (11.3)32.9 (11.3) 30.030.0
Non-affective psychosesNon-affective psychoses 36.0 (11.9)36.0 (11.9) 34.534.5 28.5 (8.9)28.5 (8.9) 26.026.0 31.8 (10.9)31.8 (10.9) 29.029.0
Affective psychosesAffective psychoses 35.4 (11.9)35.4 (11.9) 34.034.0 33.8 (11.5)33.8 (11.5) 30.030.0 34.8 (11.7)34.8 (11.7) 34.034.0
Table 2Table 2 Population at risk, number of cases (Population at risk, number of cases (nn) and incidence rates of first-contact psychosis, non-affective psychosis and affective psychosis by age group and total) and incidence rates of first-contact psychosis, non-affective psychosis and affective psychosis by age group and total
populationpopulation
AnypsychosisAnypsychosis Non-affecctiveNon-affecctive AffectiveAffective
Age group, yearsAge group, years Population at riskPopulation at risk nn Incidence (95% CI)Incidence (95% CI) nn Incidence (95% CI)Incidence (95% CI) nn IncidenceIncidence
18^2418^24 448 733448 733 100100 22.3 (18.1^27.1)22.3 (18.1^27.1) 7171 15.8 (12.4^20.0)15.8 (12.4^20.0) 2929 6.5 (4.3^9.3)6.5 (4.3^9.3)
25^2925^29 306708306708 7777 25.1 (19.8^31.4)25.1 (19.8^31.4) 5050 16.3 (12.1^21.5)16.3 (12.1^21.5) 2727 8.8 (5.8^12.8)8.8 (5.8^12.8)
30^3430^34 276320276320 4848 17.4 (12.8^23.0)17.4 (12.8^23.0) 3131 11.2 (7.6^15.9)11.2 (7.6^15.9) 1717 6.2 (3.6^9.9)6.2 (3.6^9.9)
35^3935^39 277188277188 4747 17.0 (12.5^22.5)17.0 (12.5^22.5) 2828 10.1 (6.7^14.6)10.1 (6.7^14.6) 1919 6.9 (4.1^10.7)6.9 (4.1^10.7)
40^4440^44 264,115264,115 3535 13.3 (9.2^18.4)13.3 (9.2^18.4) 1818 6.8 (4.0^10.8)6.8 (4.0^10.8) 1717 6.4 (3.8^10.3)6.4 (3.8^10.3)
45^4945^49 240345240345 2222 9.2 (5.7^13.9)9.2 (5.7^13.9) 1313 5.4 (2.9^9.3)5.4 (2.9^9.3) 99 3.7 (1.7^7.1)3.7 (1.7^7.1)
50^5450^54 205 495205495 1515 7.3 (4.1^12.0)7.3 (4.1^12.0) 99 4.4 (2.0^8.3)4.4 (2.0^8.3) 66 2.9 (1.1^6.4)2.9 (1.1^6.4)
55^5955^59 157 978157 978 1414 8.9 (4.8^14.9)8.9 (4.8^14.9) 66 3.8 (1.4^8.3)3.8 (1.4^8.3) 88 5.1 (2.2^10.0)5.1 (2.2^10.0)
60^6460^64 138323138323 99 6.5 (3.0^12.3)6.5 (3.0^12.3) 55 3.6 (1.2^8.4)3.6 (1.2^8.4) 44 2.9 (0.8^7.4)2.9 (0.8^7.4)
TotalTotal 2 3152032315203 367367 15.8 (14.3^17.6)15.8 (14.3^17.6) 231231 10.0 (8.7^11.4)10.0 (8.7^11.4) 136136 5.9 (4.9^7.0)5.9 (4.9^7.0)
F IRST- CONTACT PSYCHOS IS IN SAO PAULO, BR AZILF IRS T- CONTACT P SYCHOS IS IN SA‹ O PAULO, BRAZIL
psychosis cases were not identified due topsychosis cases were not identified due to
missing files, lack of any notes that couldmissing files, lack of any notes that could
allow checking for possible diagnosis or ad-allow checking for possible diagnosis or ad-
dress, or because they were not living at thedress, or because they were not living at the
address provided. Use of private psychiatricaddress provided. Use of private psychiatric
services not covered by the present study,services not covered by the present study,
and non-inclusion of psychoses due to in-and non-inclusion of psychoses due to in-
toxication or withdrawal of psychoactivetoxication or withdrawal of psychoactive
substances may also have contributed tosubstances may also have contributed to
the low rates. However, these cases only ac-the low rates. However, these cases only ac-
counted for small proportion of the totalcounted for small proportion of the total
number of cases of psychosis in two recentnumber of cases of psychosis in two recent
studies (Scullystudies (Scully et alet al, 2002; Kirkbride, 2002; Kirkbride et alet al,,
2006). It is unlikely that the low incidence2006). It is unlikely that the low incidence
rates might be due to non-detection of casesrates might be due to non-detection of cases
owing to premature death or to moves toowing to premature death or to moves to
other areas of the city. The main cause ofother areas of the city. The main cause of
premature death among individuals withpremature death among individuals with
psychosis is suicide (Craigpsychosis is suicide (Craig et alet al, 2006)., 2006).
However, suicide rates in Sao Paulo areHowever, suicide rates in Sa˜o Paulo are
much lower than those observed in high-much lower than those observed in high-
income countries (Mello-Santosincome countries (Mello-Santos et alet al,,
2005). Moving house because of psychotic2005). Moving house because of psychotic
breakdown is also unlikely, since aroundbreakdown is also unlikely, since around
80–90% of those with psychosis in Sao80–90% of those with psychosis in Sa˜o
Paulo live with their relatives and most relyPaulo live with their relatives and most rely
entirely on their families to surviveentirely on their families to survive
(Menezes & Mann, 1993). Therefore, even(Menezes & Mann, 1993). Therefore, even
if our rates may be slightly underestimated,if our rates may be slightly underestimated,
we nevertheless believe that we havewe nevertheless believe that we have
identified the vast majority of cases. Non-identified the vast majority of cases. Non-
systematic errors regarding diagnosis maysystematic errors regarding diagnosis may
have happened, but are not likely to explainhave happened, but are not likely to explain
the patterns observed. The areas covered bythe patterns observed. The areas covered by
the study were heterogeneous regardingthe study were heterogeneous regarding
socio-economic status of the population,socio-economic status of the population,
but there are large parts of the city withbut there are large parts of the city with
higher proportions of more deprived areas.higher proportions of more deprived areas.
This means that if the incidence of psycho-This means that if the incidence of psycho-
sis varies within city areas, and if this varia-sis varies within city areas, and if this varia-
tion is associated with neighbourhoodtion is associated with neighbourhood
socio-economic levels, the present ratessocio-economic levels, the present rates
may be also slightlyunderestimating themay be also slightly underestimating the
overall rates for the metropolis.overall rates for the metropolis.
We did not examine the possible asso-We did not examine the possible asso-
ciation between incidence of psychosis andciation between incidence of psychosis and
ethnicity. One of the marked characteristicsethnicity. One of the marked characteristics
of the Brazilian population is its ethnic ad-of the Brazilian population is its ethnic ad-
mixture. According to the Brazilian Census,mixture. According to the Brazilian Census,
which uses self-reported skin colour or eth-which uses self-reported skin colour or eth-
nicity, in the State of Sao Paulo 71% of thenicity, in the State of Sa˜o Paulo 71% of the
population classify themselves as white, 4%population classify themselves as white, 4%
as black, and 23% as mixed (Institutoas black, and 23% as mixed (Instituto
Brasileiro de Geografia e Estatıstica,Brasileiro de Geografia e Estatı´stica,
2006). Genetic studies also have shown that2006). Genetic studies also have shown that
in Brazil, ethnic phenotypes do not allowin Brazil, ethnic phenotypes do not allow
adequate classification of ethnic ancestry,adequate classification of ethnic ancestry,
because of the high levels of admixturebecause of the high levels of admixture
(Parra(Parra et alet al, 2003). Therefore, the Brazilian, 2003). Therefore, the Brazilian
population is not adequate to explorepopulation is not adequate to explore
s10 5s10 5
AUTHOR’S PROOFAUTHOR’S PROOF
Fig. 1Fig. 1 Incidence rates of non-affective (a) and affective (b) psychoses by age group among women.Incidence rates of non-affective (a) and affective (b) psychoses by age group among women.
Fig. 2Fig. 2 Incidence rates of non-affective (a) and affective (b) psychoses by age group amongmen.Incidence rates of non-affective (a) and affective (b) psychoses by age group amongmen.
MENEZES ET ALMENEZES ET AL
comparisons of incidence of psychosis bycomparisons of incidence of psychosis by
ethnic group. However, modern genotypingethnic group. However, modern genotyping
techniques are allowing more precise mea-techniques are allowing more precise mea-
surement of the amount of different geneticsurement of the amount of different genetic
ethnic ancestries in individuals, and theseethnic ancestries in individuals, and these
techniques could be used to examinetechniques could be used to examine
possible associations between degree ofpossible associations between degree of
admixture and risk of psychosis, using aadmixture and risk of psychosis, using a
case–control design.case–control design.
The studies on the outcome of schizo-The studies on the outcome of schizo-
phrenia coordinated by the WHO showedphrenia coordinated by the WHO showed
a better prognosis among those with psy-a better prognosis among those with psy-
chosis living in lower- and middle-incomechosis living in lower- and middle-income
societies (Jablenskysocieties (Jablensky et alet al, 1992). If the rela-, 1992). If the rela-
tively low incidence rates observed in thetively low incidence rates observed in the
present study are followed by a high pro-present study are followed by a high pro-
portion of recovery, then a low prevalenceportion of recovery, then a low prevalence
of psychosis would also be expected, andof psychosis would also be expected, and
that might have an impact on planningthat might have an impact on planning
and provision of mental health services.and provision of mental health services.
However, more recently the notion of aHowever, more recently the notion of a
better outcome of psychosis in lower- andbetter outcome of psychosis in lower- and
middle-income countries has been disputed,middle-income countries has been disputed,
based on some methodological limitationsbased on some methodological limitations
of the WHO studies, the lack of evidenceof the WHO studies, the lack of evidence
for specific sociocultural factors that mightfor specific sociocultural factors that might
contribute to a better prognosis of psycho-contribute to a better prognosis of psycho-
sis, new data showing a gloomier picturesis, new data showing a gloomier picture
for the prognosis of psychosis in somefor the prognosis of psychosis in some
lower- and middle-income societies, andlower- and middle-income societies, and
on important economic and demographicon important economic and demographic
changes that are taking place in manychanges that are taking place in many
lower- and middle-income countries (Patellower- and middle-income countries (Patel
et alet al, 2006). Indeed, Sao Paulo follows more, 2006). Indeed, Sa˜o Paulo follows more
closely the patterns of living conditions andclosely the patterns of living conditions and
social demands found in industrialisedsocial demands found in industrialised
societies, and therefore the prognosis ofsocieties, and therefore the prognosis of
psychosis may not be a favourable one.psychosis may not be a favourable one.
Follow-up of the present first-contactFollow-up of the present first-contact
cohort will help to answer this issue.cohort will help to answer this issue.
Recent studies are helping to show howRecent studies are helping to show how
the observed variation in incidence ratesthe observed variation in incidence rates
between different ethnic or social groupsbetween different ethnic or social groups
may be at least partly explained by hetero-may be at least partly explained by hetero-
geneous distribution of psychosocial riskgeneous distribution of psychosocial risk
factors (Wicksfactors (Wicks et alet al, 2005; Morgan, 2005; Morgan et alet al,,
2006). Similar investigations in different2006). Similar investigations in different
settings (large and smaller urban centres,settings (large and smaller urban centres,
rural areas) from lower- and middle-incomerural areas) from lower- and middle-income
countries must be carried out in order tocountries must be carried out in order to
contribute to a better understanding of thecontribute to a better understanding of the
determinants of the incidence of thesedeterminants of the incidence of these
disorders.disorders.
ACKNOWLEDGEMENTSACKNOWLEDGEMENTS
We thank all the research staff involved in the fieldWe thank all the research staff involved in the field
work of this study, all institutions and psychiatristswork of this study, all institutions and psychiatrists
that allowed access to medical records and patients,that allowed access to medical records and patients,
and the University Hospital of the University of Saoand the University Hospital of the University of Sa‹ o
Paulo. P.R.M. and M.S. are partly funded by CNPq-Paulo. P.R.M. and M.S. are partly funded by CNPq-
Brazil. The present work was funded by TheBrazil. The present work was funded by The
WellcomeWellcomeTrust.Trust.
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s10 6s10 6
AUTHOR’S PROOFAUTHOR’S PROOF
PAULOR.MENEZESPAULOR.MENEZES,MD, PhD,Department of Preventive Medicine, Faculty of Medicine and Section of,MD, PhD,Department of Preventive Medicine, Faculty of Medicine and Section of
Epidemiology,University Hospital,University of Sao Paulo, Sao Paulo,Brazil;Epidemiology,University Hospital,University of Sa‹ o Paulo, Sa‹ o Paulo,Brazil; MARCIA SCAZUFCAMARCIA SCAZUFCA, PhD,, PhD,
Department of Psychiatry, Faculty of Medicine, and Section of Epidemiology,University Hospital,University ofDepartment of Psychiatry, Faculty of Medicine, and Section of Epidemiology,University Hospital,University of
Sao Paulo, Sao Paulo,Brazil;Sa‹ o Paulo, Sa‹ o Paulo,Brazil; GERALDO F.BUSATTOGERALDO F.BUSATTO,MD, PhD,Department of Psychiatry, Faculty of Medicine,,MD, PhD,Department of Psychiatry, Faculty of Medicine,
University of Sao Paulo, Sao Paulo,Brazil;University of Sa‹ o Paulo, Sa‹ o Paulo,Brazil; LETICIAM. S.COUTINHOLETI¤CIA M. S.COUTINHO,CStat,Department of Preventive,CStat,Department of Preventive
Medicine, Faculty of Medicine and Section of Epidemiology,University Hospital,University of Sao Paulo, SaoMedicine, Faculty of Medicine and Section of Epidemiology,University Hospital,University of Sa‹ o Paulo, Sa‹ o
Paulo,Brazil;Paulo,Brazil; PHILIP K.MPHILIP K.MccGUIREGUIRE,MD, PhD,,MD, PhD, ROBINM.MURRAYROBINM.MURRAY, FRCPsych,Department of Psychological, FRCPsych,Department of Psychological
Medicine, Institute of Psychiatry, London,UKMedicine, Institute of Psychiatry, London,UK
Correspondence: Professor Dr Paulo R.Menezes,Department of Preventive Medicine,University of Sao PauloCorrespondence: Professor Dr Paulo R.Menezes,Department of Preventive Medicine,University of Sa‹ o Paulo
Medical School, Av.Dr. Arnaldo 455, Sao Paulo^SP,Brazil,CEP 01246-903. Email: pmenezesMedical School, Av.Dr. Arnaldo 455, Sao Paulo^SP,Brazil,CEP 01246-903. Email: pmenezes@@usp.brusp.br
10.1192/bjp.191.51.s102Access the most recent version at DOI: 
2007, 191:s102-s106.BJP 
PHILIP K. McGUIRE and ROBIN M. MURRAY
PAULO R. MENEZES, MARCIA SCAZUFCA, GERALDO F. BUSATTO, LETÍCIA M. S. COUTINHO,
Incidence of first-contact psychosis in São Paulo, Brazil
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