Multidimensional Approach to Exploring Neighborhood Determinants and Symptom Severity Among Individuals With Psychosis

Importance The impact of cumulative exposure to neighborhood factors on psychosis, depression, and anxiety symptom severity prior to specialized services for psychosis is unknown. Objective To identify latent neighborhood profiles based on unique combinations of social, economic, and environmental factors, and validate profiles by examining differences in symptom severity among individuals with first episode psychosis (FEP). Design, Setting, and Participants This cohort study used neighborhood demographic data and health outcome data for US individuals with FEP receiving services between January 2017 and August 2022. Eligible participants were between ages 14 and 40 years and enrolled in a state-level coordinated specialty care network. A 2-step approach was used to characterize neighborhood profiles using census-tract data and link profiles to mental health outcomes. Data were analyzed March 2023 through October 2023. Exposures Economic and social determinants of health; housing conditions; land use; urbanization; walkability; access to transportation, outdoor space, groceries, and health care; health outcomes; and environmental exposure. Main Outcomes and Measures Outcomes were Community Assessment of Psychic Experiences 15-item, Patient Health Questionnaire 9-item, and Generalized Anxiety Disorder 7-item scale. Results The total sample included 225 individuals aged 14 to 36 years (mean SD age, 20.7 4.0 years; 152 men 69.1%; 9 American Indian or Alaska Native 4.2%, 13 Asian or Pacific Islander 6.0%, 19 Black 8.9%, 118 White 55.1%; 55 Hispanic ethnicity 26.2%). Of the 3 distinct profiles identified, nearly half of participants (112 residents 49.8%) lived in urban high-risk neighborhoods, 56 (24.9%) in urban low-risk neighborhoods, and 57 (25.3%) in rural neighborhoods. After controlling for individual characteristics, compared with individuals residing in rural neighborhoods, individuals residing in urban high-risk (mean estimate SE, 0.17 0.07; P = .01) and urban low-risk neighborhoods (mean estimate SE, 0.25 0.12; P = .04) presented with more severe psychotic symptoms. Individuals in urban high-risk neighborhoods reported more severe depression (mean estimate SE, 1.97 0.79; P = .01) and anxiety (mean estimate SE, 1.12 0.53; P = .04) than those in rural neighborhoods. Conclusions and Relevance This study found that in a cohort of individuals with FEP, baseline psychosis, depression, and anxiety symptom severity differed by distinct multidimensional neighborhood profiles that were associated with where individuals reside. Exploring the cumulative effect of neighborhood factors improves our understanding of social, economic, and environmental impacts on symptoms and psychosis risk which could potentially impact treatment outcomes.