Review of Major Social Determinants of Health in Schizophrenia-Spectrum Psychotic Disorders: I. Clinical Outcomes

Abstract

Background: Social determinants of health (SDoHs) are receiving growing attention and are particularly relevant to persons with schizophrenia-spectrum psychotic disorders (SSPDs), considering their heightened risk of comorbidities, cognitive and functional decline, and early mortality. Yet, we did not find any comprehensive review of multiple SDoHs in SSPD.

Study design: We conducted a scoping review of meta-analyses and systematic reviews of nine major SDoHs in SSPD.

Study results: Childhood abuse, parental psychopathology, parental communication problems, bullying, and urban settings with lower socioeconomic status were major risk factors for the greater incidence of SSPD and/or worse health. Social network size was inversely associated with overall psychopathology and negative symptoms. Experiences of racial/ethnic discrimination correlated with the prevalence of psychotic symptoms and experiences. Compared to native populations, the risk of psychosis was higher in immigrants, refugees, and asylees. Social fragmentation was associated with an increased prevalence of schizophrenia. Homeless populations had a 30-fold higher prevalence of schizophrenia than the general population. Seriously mentally ill people were 2.7 times more likely to report food insecurity than controls. The prevalence of non-affective psychosis in prisoners was 2.0%-6.5%, compared to 0.3% in the general population. Certain potentially positive factors like family and community resilience remain poorly studied.

Conclusions: SDoHs are associated with higher rates of and worse outcomes in SSPD. Well-designed longitudinal studies are needed to understand SDoHs' contribution to health in persons with SSPD, to develop interventions, and to implement changes in clinical care and public health policies that would reduce adverse health impacts of SDoHs. Positive SDoHs deserve greater attention.

Keywords: childhood trauma; homelessness; immigration; poverty; racism; social connections.

Fig. 1.

Prisma flow chart. Note: Originally, we sought to conduct a systematic review of SDoHs in schizophrenia using three electronic databases—PsycINFO, PubMed, and Web of Science, in July 2022. Key terms included “schizophrenia” OR “schizoaffective” AND “social determinant”. A total of 328 articles were found, and 259 were screened for selection following a deletion of duplicates. After reviewing abstracts and full texts, we found that no article measuring specific SdoHs, that included the search term “social determinant” in their abstracts or texts, despite measuring individual domains within the construct. Therefore, we completed the following search below in PubMed, PsycINFO, and Web of Science and transitioned to a scoping review framework. Search Terms: ((schizophrenia OR “schizophrenia-spectrum disorder”) AND (meta-analysis) AND (“social network” OR “social isolation” OR “social support” OR “emotional support” OR “instrumental support” OR “relationship quality” OR “marital” OR “social fragmentation” OR “abuse” OR “neglect” OR “adversity” OR “discrimination” OR “racism” OR “prison*” OR “imprison*” OR “incarcerat*” OR “prenatal” OR “perinatal” OR “immigration” OR “migration” OR “refugee” OR “displace*” OR “rural*” OR “urban*” OR “educational quality” OR “educational access” OR “employ*” OR “occupational environment” OR “vocational environment” OR “work environment” OR “food insecurity” OR “food desert” OR “homeless*” OR “houseless*” OR “unhoused” OR “healthcare” OR “insurance” OR “socioeconomically deprived” OR “poverty” OR “impoverish*” OR “socioeconomic” OR “stigma*” OR “victim*” OR “neighborhood” OR “environment” OR “community” OR “religio*” OR “spirit*”))