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The French West Indies (FWI) are part of the Caribbean region and comprise 2 main islands: Martinique (n = 381 500 individuals) and Guadeloupe (n = 421 600 individuals), with an area of 1130 km2 and 1704 km2, respectively. Afro-Caribbeans who are fluent in both French and Creole (owing to education levels equivalent to continental France) comprise the island majority. Foreigners consist mainly of Dominicans, Saint Lucians, and Haitians. The population age pyramid shows that in 1999, 23% of inhabitants were aged under 15 years. The FWI have a growing economy, with a significant increase in per capita gross domestic product (GDP); for example, between 1989 and 1999 the GDP in Martinique increased from US$7260 to US$12 240 (1). Although the FWI are politically linked to France and part of the European Union, to our knowledge no epidemiologic study has been performed concerning the prevalence of psychiatric disorders. Despite many reports spanning 2 decades that suggest a possible excessive rate of psychoses among the Afro-Caribbean population living in England (2–5), we are unaware of any study having established a similar difference in the rate of psychoses between the FWI and continental France. ObjectiveWe compared the lifetime prevalence of psychoses in the FWI and in continental France, using a multicentre epidemiologic study performed in a general population under the authority of the World Health Organization French Collaborating Center (WHO-CC). MethodBetween 1998 and 2001, we selected 7257 individuals representative of the general population, using a random sampling (that is, quota method) of 900 people per site. The quota method applies the same proportions of criteria, such as age, sex, socioeconomic status, and place of residence, in the sample as in the general population. After providing clear information concerning the study, we obtained written consent from study participants and then conducted face-to-face interviews. The WHO-CC analyzed data from 9 different sites: 7 French sites (that is, Hauts de Seine, Lille, Vallée de la Lys, East Pyrenees, Nantes, Marseille, and Tourcoing) and 2 FWI sites (that is, Guadeloupe and Martinique). In each site, the epidemiologic data were collected using the Mini International Neuropsychiatric Interview (MINI) (6). The MINI is a joint American and French concept based on the ICD-10 and DSM-IV classifications. With reference to the Composite International Diagnostic Interview (CIDI), we established validity and reliability regarding psychiatric and nonpsychiatric patients. Prior to our study, preliminary investigation of interrater reliability was estimated to be between a kappa value of 0.79 for ICD-10 diagnosis of an isolated episode of psychosis and 0.83 for long-term psychosis. An expert team created a French–Creole translation using the double translation approach; however, Creole was rarely used (0.2%) because most subjects interviewed spoke French. Over a 3-day session, WHO-CC experts used the same methodology and instructions to train all study interviewers at each of the sites. We selected interviewers from members of the local populations, and a senior psychiatrist, in collaboration with the interviewer assigned to each study participant, completed the questionnaire evaluations. We included the F20 to F29 categories of the ICD-10 (7) in the diagnosis of psychoses. We performed statistical analyses using Epi Info (8), and we compared group data, using the chi-square test for dichotomous variables. ResultsOf the total 5502 individuals interviewed, 99 subjects (1.8%) with psychoses were identified in the 7 French sites. At the 2 FWI sites (that is, Guadeloupe and Martinique), we observed 78 individuals (4.4%) with psychoses out of a total number of 1755 individuals interviewed. The prevalence of psychoses was significantly higher in the FWI sample than in the French continental sample (c2 = 35.22, df 1, P < 0.0001). Several sites did not interview the total number of subjects involved in their sample. However, since the proportions of the quota method were always respected, we believe that the following results remain methodologically correct: Hauts de Seine, 900; Lille, 608; Vallée de la Lys, 902; East Pyrenees, 885; Nantes, 413; Marseille, 893; Tourcoing, 901; Guadeloupe, 855; and Martinique, 900. DiscussionWe analyzed the literature concerning excess of psychoses in the Caribbean population, using the following key words in Medline: African, Caribbean, Afro-Caribbean, psychosis, and psychoses. We supplemented the latter inquiry with a detailed search through available reference lists. The debate over possible excess of psychoses among Afro-Caribbeans living in England was focused primarily on 2 time periods: before the UK census of 1991, which introduced ethnic data about the general population in England, and after the UK census. It appeared obvious that the later studies, which benefit from the census figures, were more reliable and credible than the studies conducted before the UK census. The study results tended toward high rates of psychoses among Caribbeans living in England (3,5). In contrast to the latter findings, several authors did not report an increased rate of schizophrenia among the Caribbeans still living in their native countries (9–12). These results were in fact consistent with other studies, which suspected that the migration of individuals from a given community was a possible factor in the genesis of psychoses in the adopted country (5,13). Because the MINI does not permit the diagnosis of various forms of psychoses with any degree of specificity, we could not draw a parallel between these studies and our own findings. In our sample of populations still living in the FWI, our findings of excess psychoses appeared consistent with a new trend in current literature (14) that suggests a need to revisit the migration hypothesis established several decades ago by Odegaard (13). We felt compelled to interpret our results with more circumspection and to raise some hypotheses in an attempt to explain the discrepancy in rates of psychoses between populations with the same cultural background living in different countries. In our sample, a possible confounding factor could be that we do not know the rate for French West Indians who lived in France for a sustained period of time as first or second-generation immigrants and who returned to the FWI. Further, we do not know the rate of psychoses among the FWI population living in continental France (this has not yet been studied). The latter 2 factors may have skewed our results toward an abnormally high rate of psychoses. Although the WHO-CC justified selection of the questionnaire based on the MINI (15), the MINI has not been validated in the FWI. In interpreting our results, we tend to favour the views and hypotheses in Sharpley and colleagues (16), who suggest that drug abuse and supernatural interpretation of daily events, as well as mood disorders with psychosis, may play a significant role in the genesis of psychoses. Therefore, abnormally high rates of psychoses could be owing to a recent and significant abuse of cannabis and crack cocaine in the FWI (17): both drugs are well known for their potential to induce or produce psychotic disorders (18,19). Finally, many French African-Caribbeans tend to think in a magical manner and at times to be involved in magical practices. The MINI, designed primarily for Western nations, may overestimate the rate of psychoses in non-Western nations. Further, some individuals express depression in a psychotic form, as has been described in several African countries (20). These manifestations, although clinically perceived as psychoses, are actually akin to mood disorders and typically respond to antidepressant medications. ConclusionWe found a significant excess of psychoses in a representative sample of the general population living in the FWI, compared with the population of continental France. This provides further insight into the inadequacy of the classical migration hypothesis as a sole explanation; we suggest that other hypotheses also be considered. Funding and SupportFinancial support was provided by the French Ministry of Foreign Affairs, French Ministry of Health, WHO-Geneva (Nations for Mental Health Program), the WHO local office in Moroni (The Comoros), the WHO local office in Antananarivo (Madagascar), the health systems research for reproductive health and health care reforms in the Eastern and Southern African region (Harare, Zimbabwe), the Nord Pas de Calais regional direction of health and social services (DRASS), the Ile de France and Réunion regional agencies of hospitalization, and the Synthelabo and SmithKline and Beecham companies. AcknowledgementsWe thank M-A Marine, M Michalon, F Montredon, N Nelzy, S Nogard, F Oliny, M Paris, S Paulin, V Petit-Jean-Roget, R Robert, J Rosine, O Terosier, N Verroux, and M-N Vitulin. References1. Merle S. French Guyana, Guadeloupe, and Martinique. In: Pan American Health Organization Edition. Health in the Americas. Scientific and technical publication 2002; 280–7. Report No 587. 2. Bebbington P, Hurry J, Tennant C, Sturt E, Wing JK. Epidemiology of mental disorders in Camberwell. Psychol Med 1981;11:561–79. 3. Bhugra D, Leff J, Mallett R, Der G, Corridan B, Rudge S. Incidence and outcome of schizophrenia in Whites, African-Caribbeans, and Asians in London. Psychol Med 1997;27:791–98. 4. Cochrane R, Bal SS. Mental hospital admission rates of immigrants to England: a comparison of 1971 and 1981. Soc Psychiatry Psychiatr Epidemiol 1989;24:2–11. 5. King M, Coker E, Leavey G, Hoare A, Johnson-Sabine E. Incidence of psychotic illness in London: comparison of ethnic groups. BMJ 1994;309:1115–9. 6. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, and others. The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59(Suppl 20):22–33. 7. Pull CB. Troubles mentaux et du comportement. Critères diagnostiques pour la recherche. In: Masson SA, editor. CIM-10/ICD-10. Classification internationale des maladies. 10th révision. Paris: Masson SA; 1994. p 343–51. 8. Epi Information. French Version 5.0b ENSP. Atlanta (GA): Center for Disease Control; April 1992. 9. Bhugra D, Hilwig M, Hossein B, Marceau H, Neehall J, Leff J, and others. First-contact incidence rates of schizophrenia in Trinidad and one-year follow-up. Br J Psychiatry 1996;169:587–92. 10. Bhugra D, Hilwig M, Mallett R, Corridan B, Leff J, Neehall J, and others. Factors in the onset of schizophrenia: a comparison between London and Trinidad samples. Acta Psychiatr Scand 2000;101:135–41. 11. Hickling FW, Rodgers-Johnson P. The incidence of first contact schizophrenia in Jamaica. Br J Psychiatry 1995;167:193–6. 12. Mahy GE, Mallett R, Leff J, Bhugra D. First-contact incidence rate of schizophrenia on Barbados. Br J Psychiatry 1999;175:28–33. 13. Odegaard O. Emigration as insanity: a study of mental disease among Norvegian-born population in Minnesota. Acta Psychiatria et Neurologia Scandinavica 1932;7:1–206. 14. Zolkowska K, Cantor-Graae E, McNeil TF. Increased rates of psychosis among immigrants to Sweden: is migration a risk factor for psychosis? Psychol Med 2001;31:669–78. 15. Roelandt JL, Caria A, Anguis M, Benoist B, Bryden B, Defromont L. La santé mentale en population générale: image et réalité. Available: www.epsm_lille_metropole.fr. 2001. 2001. 16. Sharpley MS, Hutchinson G, Murray RM, McKenzie K. Understanding the excess of psychosis among the African-Caribbean population in England: review of current hypotheses. Br J Psychiatry 2001;178:S60–S68. 17. Merle S, Giboyau J, Charles-Nicolas A. Epidémiologie de la toxicomanie en Martinique. In: l’Harmattan, editor. Crack et cannabis dans la Caraïbe. Paris:1997;191–7. 18. Zammit S, Allebeck P, Andreasson S, Lundberg I, Lewis G. Self reported cannabis use as a risk factor for schizophrenia in Swedish conscripts of 1969: historical cohort study. BMJ 2002;325:1195–212. 19. Farrell M, Boys A, Bebbington P, Brugha T, Coid J, Jenkins R, and others. Psychosis and drug dependence: results from a national survey of prisoners. Br J Psychiatry 2002;181:393–8. 20. Hanck C, Collomb H, Boussat M. Psychotic masked depression or black mask for depression. Acta Psychiatr Belg 1976;76:26–45. AppendixThe survey was carried out by the Association Septentrionale d’Epidémiologie psychiatrique (ASEP), with the department of medical information of the psychiatric hospital of Lille and the World Health Organization Collaborating Center for research and training in mental health–Paris (CCOMS). The survey was made possible by the logistical support of the mental health public hospitals concerned with the research and the participation of interviewers and supervisors in the research sites. Author(s)Manuscript received April 2003, revised, and accepted January 2004. 1. Psychiatrist, Department of Psychiatry, University Hospital of Fort de France, Martinique. 2. Psychiatrist, Psychiatric Hospital of Colson, Martinique. 3. Epidemiologist, Regional Health Observatory, Martinique. 4. Psychiatrist, Psychiatric Hospital of Saint Claude, Guadeloupe. 5. Psychiatrist, Professor of Psychiatry, Department of Psychiatry, University Hospital of Fort de France, Martinique. Address for correspondence: Dr N Ballon, Service de psychiatrie, CHU de Fort de France, BP 632, 97261 Fort de France, French West Indies. e-mail: ballon@informatique2000.fr
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