Journal of Psychiatric Research 148 (2022) 197–203

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Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/jpsychires

Conditional associations between childhood cat ownership and psychotic

experiences in adulthood: A retrospective study
Vincent Paquin a, b, Guillaume Elgbeili b, Julia Munden a, Norbert Schmitz a, c, Ridha Joober a, b,
Antonio Ciampi c, Suzanne King a, b, *
a
Department of Psychiatry, McGill University, Montreal, Canada
b
Douglas University Mental Health Institute, Montreal, Canada
c
Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada

A R T I C L E I N F O A B S T R A C T

Keywords: Ownership of cats in childhood has been inconsistently associated with psychosis in adulthood. Parasitic
Psychotic disorders exposure, the putative mechanism of this association, may be more common with rodent-hunting cats, and its
Toxoplasma association with psychosis may depend on other environmental exposures. We examined the conditional asso­
Machine learning
ciations between childhood cat ownership and the frequency of psychotic experiences in adulthood. Adults (n =
Craniocerebral trauma
2206) were recruited in downtown Montreal to complete a survey about childhood cat ownership (non-hunting
or rodent-hunting), winter birth, residential moves in childhood, head trauma history, and tobacco smoking. The
frequency of psychotic experiences (PE) was measured with the 15-item positive subscale of the Community
Assessment of Psychic Experiences. Associations between exposures and PE were examined in linear regressions
adjusted for age and sex. Interactions among variables were explored using a conditional inference tree. Rodent-
hunting cat ownership was associated with higher PE scores in male participants (vs. non-hunting or no cat
ownership: SMD = 0.57; 95% CI: 0.27, 0.86), but not in female participants (SMD = 0.10; 95% CI: − 0.18, 0.38).
In the conditional inference tree, the highest mean PE score was in the class comprised of non-smokers with >1
residential move, head trauma history, and rodent-hunting cat ownership (n = 22; mean standard score = 0.96).
The interaction between rodent-hunting cat ownership and head trauma history was supported by a post-hoc
linear regression model. Our findings suggest childhood cat ownership has conditional associations with psy­
chotic experiences in adulthood.

1. Introduction association between cat ownership and psychotic experiences in humans

Toxoplasma gondii is a candidate causal risk factor for psychosis. This
protozoan parasite is typically transmitted to humans by domestic cats
(Dubey, 1998). A seminal case-control study by Torrey and Yolken
(1995) showed an association between cat ownership during childhood
and the risk for severe mental illness in adulthood. Subsequently, it was
found that seropositivity for T. gondii is associated with a greater number
of psychotic experiences in the general population (Lindgren et al.,
2018), and with a higher risk for schizophrenia (Sutterland et al., 2015).
Additional evidence comes from animal research showing, for example,
that T. gondii infection is associated with activated microglia and syn­
aptic loss (Carrillo et al., 2020), two mechanisms that are thought to be
involved in the pathogenesis of schizophrenia in humans (Howes and
McCutcheon, 2017). Other studies, however, could not demonstrate an
(e.g., Bedwell et al., 2020).
The association between cat ownership and psychotic experiences
may be conditional on other factors. Domestic cats generally become
infected with the parasite by feeding on rodents, and will only be con­
tagious during the days or weeks that follow (Dubey, 1998). Hence,
specifying whether the cat was known to hunt rodents might provide a
better proxy for probable exposure to T. gondii compared to cat
ownership alone. Another consideration is that the association between
cat ownership and psychotic experiences may be sexually dimorphic:
studies in humans have identified male-specific associations between
T. gondii infection and behavior or physiology (Flegr et al., 2008, 2011).
Further, as suggested by the multi-hit model of schizophrenia (Davis
et al., 2016; Howes and McCutcheon, 2017), the presence or absence of
other environmental risk factors may influence the association between

* Corresponding author. Mental Health and Society Division, Douglas Research Centre, 6875, boulevard LaSalle, Montreal, QC, H4H 1R3, Canada.
E-mail address: suzanne.king@mcgill.ca (S. King).

https://doi.org/10.1016/j.jpsychires.2022.01.058
Received 2 May 2021; Received in revised form 16 November 2021; Accepted 26 January 2022
Available online 30 January 2022
0022-3956/© 2022 Elsevier Ltd. All rights reserved.
V. Paquin et al.
cat ownership and psychosis expression.
Identifying interactions among environmental exposures is an
analytical challenge. Environmental risk factors for psychosis are largely
interconnected (Guloksuz et al., 2018; Paquin et al., 2020). The ability
of common statistical models, such as linear regressions, to detect in­
teractions will depend on the data analyst’s decisions of which covari­
ables to include, and which interactions to test for (Guloksuz et al.,
2018; Venkatasubramaniam et al., 2017). Decision tree learning is a
statistical approach that allows data-driven exploration of interactions
among predictor variables, which are selected by means of an algorithm.
This approach generates tree-shaped models of the outcome’s distribu­
tion according to the status of selected predictor variables (Hothorn
et al., 2006; Venkatasubramaniam et al., 2017). This simple approach to
machine learning can uncover potential interactions among predictors
and identify subgroups of participants who share homogeneous expo­
sure profiles and symptom levels.
Using retrospective assessments of environmental exposures in a
community sample, we first aimed to examine the association between
rodent-hunting cat ownership in childhood and psychotic experiences in
adulthood. Second, we evaluated whether this association was sexually
dimorphic. Third, using decision tree learning, we explored potential
interactions between cat ownership and other risk factors for psychotic
experiences.
2. Methods
2.1. Participants
This retrospective study was conducted as part of the EnviroGen
project, the aim of which was to characterize environmental and genetic
risk factors for psychosis (King et al., 2005). Adults were approached in
public places in downtown Montreal, Canada to complete a question­
naire about “unusual psychic experiences”. Participants were required
to be between 18 and 40 years of age and to live in the greater Montreal
area. Participants were offered a 1:25 chance of winning $50 if they
provided contact information. Questionnaires were completed on site
and were available in both French and English. Written informed con­
sent was given by all participants. This study was approved by the
Research Ethics Board of the Douglas Research Center.
2.2. Assessments
Psychotic experiences (PE). Participants completed the 42-item
Community Assessment of Psychic Experiences (CAPE-42) (Brenner
et al., 2007; Stefanis et al., 2002). From this scale, the 15-item positive
subscale (CAPE-P15) (Capra et al., 2013) was extracted. Its items
examine the lifetime occurrence of hallucinatory-like (e.g., hearing
voices when alone), delusional-like (e.g., feeling persecuted) and other
unusual experiences (e.g., feeling as though one’s thoughts have been
withdrawn from self). The frequency of each item is self-reported on a
4-point scale, from “never” (1) to “nearly always” (4). The global score is
the mean weighted frequency of all items. The CAPE-P15 has been
shown to have good internal consistency, test-retest reliability, construct
validity and clinical validity (Bukenaite et al., 2017; Capra et al., 2013;
Sun et al., 2020).
Risk factors. Participants also completed an ad-hoc questionnaire (see
Supplementary Material) evaluating the presence or absence of the
following putative risk factors for psychosis: cat ownership at any time
between birth and age 13, number of residential moves between birth
and age 15 (Paksarian et al., 2020), winter birth (Tochigi et al., 2013),
lifetime history of head trauma (Orlovska et al., 2014), and daily to­
bacco smoking (Bhavsar et al., 2018). Participants who had cats in
childhood were asked if their cats were known to catch rodents. Cat
hunting behaviors as reported by cat owners were previously shown to
be associated with T. gondii seroprevalence in the cats (Opsteegh et al.,
2012). We created a 3-factor cat variable: no cat, non-hunting cat
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Journal of Psychiatric Research 148 (2022) 197–203
ownership, and rodent-hunting (i.e., rodent-catching) cat ownership.
Participants were also asked about their date and place of birth and their
level of education. Winter birth was defined as birth in the northern
hemisphere between December and March.
2.3. Statistical analysis
Analyses were performed in R version 3.6.1 (R Foundation for Sta­
tistical Computing). P-values below .05 (two-tailed) were considered
significant. Participants with missing data on any of the modeled vari­
ables were removed from the analyses. We conducted descriptive ana­
lyses of all participants and compared those included and excluded from
primary analyses due to missingness. For linear regression and decision
tree models, we standardized PE scores (i.e., mean = 0, standard devi­
ation [SD] = 1) to facilitate the interpretation of between-individual
differences.
We used linear regression models to examine the associations be­
tween cat ownership and PE standard scores. For exploratory purposes,
we also reported linear regression models of PE on the other variables:
sex, age, winter birth, residential moves, head trauma history, and
smoking. Each exposure variable was examined in a separate model
adjusted for sex and age. We tested the two-way interaction between sex
and cat ownership; standardized mean differences (SMD) in PE
depending on cat ownership-by-sex were adjusted for multiple com­
parisons using the Tukey method (Lenth, 2020). SMD were interpreted
as small (0.2), medium (0.5) and large (0.8) (Cohen, 1988).
As a sensitivity analysis for missingness, the aforementioned re­
gressions were fitted on the total sample (n = 2206) imputed with a 5-
nearest neighbor algorithm (Kowarik and Templ, 2016). As a sensi­
tivity analysis for generalizability, the regressions were fitted using
sample weights derived from Montreal census data (Table S1). Raking
ratio estimation (Kalton and Flores-Cervantes, 2003; Lumley, 2020) was
applied to calibrate weights to sex, migration status and educational
attainment.
We used decision tree learning to explore for other interactions
among the exposure variables (Venkatasubramaniam et al., 2017). This
type of machine learning involves recursive partitioning of the data,
whereby the source dataset is split into multiple subsets based on sta­
tistical rules. Here, we generated decision trees to predict PE standard
scores based on the status of the exposure variables. We first compared
the performance of three decision tree algorithms: conditional inference
trees with Bonferroni corrections, conditional inference trees with the
Monte Carlo method, and classification and regression trees. In classi­
fication and regression trees (Breiman, 1984), predictor variables and
their cutoffs are selected to minimize the relative sum square of errors.
In contrast, conditional inference trees (Hothorn et al., 2006) select
predictor variables and their cutoffs according to permutation tests,
which are non-parametric and unbiased for predictor selection. We also
tested linear regressions comprising all the exposure variables, as well as
generalized linear models using least absolute shrinkage and selection
operator (LASSO) (Friedman et al., 2021) with α = 1. We trained our
models on 75% of the total dataset and cross-validated their perfor­
mances on the remaining 25% of data. We compared the average per­
formances of the different models by running 10 iterations of each on
randomly split datasets.
3. Results
3.1. Descriptive statistics and correlations
Of 3208 participants deemed eligible, 2470 agreed to complete the
questionnaire (77.0% acceptance), and of those, 2206 were confirmed to
be eligible. In the total sample (n = 2206), there was no missing data on
PE but 7–26% missing data on the exposure variables. Participants
included in primary analyses were those with complete data (n = 1986;
90.0% of the sample).
V. Paquin et al. Journal of Psychiatric Research 148 (2022) 197–203

Descriptive analyses are presented in Table 1. The mean PE score was 3.2. Associations between risk factors and psychotic experiences
1.46 (SD = 0.30). Based on the descriptive statistics and predictive
models (see below), we dichotomized age as 0: >21 years, and 1: ≤21 Rodent-hunting cat ownership, but not non-hunting cat ownership,
years. Compared with participants excluded due to missing data, was associated with higher PE scores compared to no cat ownership
included participants had lower PE scores and were more likely to have (Table 2). Winter birth and 1–2 residential moves (relative to none) did
high school education or less and to be born during winter. Compared not display significant associations with the outcome. Age ≤21 years,
with the general population of Montreal, included participants were less having had 3–5 or 6+ residential moves, as well as head trauma history
likely to be immigrants and to have lower educational attainment and smoking, were associated with higher PE scores. Results were
(Table S1). similar in regression models using age as a continuous variable
(Table S2). Sensitivity analyses with sample weights (Table S3) and with
the full, imputed dataset (n = 2206; Table S4) also yielded consistent
results.
There was a significant interaction between rodent-hunting cat
Table 1 ownership and male sex: coefficient = 0.23, standard error (SE) = 0.11, t
Description of included and excluded participants on psychotic experiences, (1979) = 2.23, p = .03. In male participants, rodent-hunting cat
demographic characteristics and environmental exposures.
ownership was associated with higher PE scores (medium effect size)
Included Excluded % missing in excluded compared to non-hunting cat or no cat ownership: SMD = 0.57; 95%
participants
N = 1986 N = 220 confidence interval (CI): 0.27, 0.86. In female participants, this differ­
PE, Mean (SD) 1.45 (0.29) 1.50 0
ence was not significant: SMD = 0.10; 95% CI: − 0.18, 0.38. Alterna­
(0.34) tively, male sex was associated with more PE compared to female sex,
Age group, N (%): 0 but only in participants who owned a rodent-hunting cat: SMD = 0.30;
18–21 years 394 40 95% CI: 0.13, 0.47.
(19.8%) (18.2%)
22–27 years 1008 107
(50.8%) (48.6%) 3.3. Decision tree selection and interaction exploration
28–33 years 386 42
(19.4%) (19.1%)
34–40 years 198 31
Performance analyses and variable importance lists of the decision
(9.97%) (14.1%) trees and regression models can be viewed interactively here: https://vi
Sex, N (%): <1 ncepaquin.shinyapps.io/Cats_and_Rats/. Predictive performances aver­
Female 1030 101 aged over 10 iterations were similar for all three decision tree models
(51.9%) (46.1%)
(conditional inference trees with Bonferroni corrections: mean R2 =
Male 956 118
(48.1%) (53.9%) 3.0%; 95% CI: 2.1, 3.9%; with Monte Carlo method: mean R2 = 3.1%;
Lower educational 0 95% CI: 2.3, 3.8%; classification and regression trees: mean R2 = 3.3%;
attainment, N (%): 95% CI: 2.4, 4.1%). Decision trees underperformed linear regressions
No 1784 207 (mean R2 = 5.5%; 95% CI: 4.5, 6.5%) for prediction. LASSO regressions
(89.8%) (94.1%)
(mean R2 = 5.5%; 95% CI: 4.4, 6.5%) performed similarly to linear
Yes 202 13
(10.2%) (5.91%) regression models comprising all the predictor variables. Of note, in 8 of
Winter birth, N (%): 25.9 the 10 linear regression models comprising all the predictor variables,
No 1601 143 rodent-hunting cat ownership (reference category: no or non-hunting
(80.6%) (87.7%)
cat ownership) was significantly associated with PE scores.
Yes 385 20
(19.4%) (12.3%) We chose the conditional inference tree algorithm with Bonferroni
Cat ownership, N (%): 13.2 corrections for its statistical interpretability and methodological
No cat 995 98 robustness. Across iterations of this algorithm, cutoff for age was set
(50.1%) (51.3%) between 19 and 22 years; for easier interpretability, we refitted the
Non-hunting cat 447 41
models with age dichotomized at 21 years and obtained similar per­
(22.5%) (21.5%)
Rodent-hunting cat 544 52 formances (mean R2 = 3.1%; 95% CI: 2.2, 4.0%).
(27.4%) (27.2%) Among the 10 iterations of conditional inference trees with Bonfer­
Residential moves, N (%): 11.4 roni corrections and dichotomous age, we selected the fourth iteration
0 518 56
(Fig. 1) because it provided the best performance on cross-validation: R2
(26.1%) (28.7%)
1–2 738 68
(37.2%) (34.9%) Table 2
3–5 509 41 Linear regressions of psychotic experience (PE) standard scores on exposures.
(25.6%) (21.0%)
6+ 221 30 Risk factor Coefficient 95% CI Standard error t p
(11.1%) (15.4%) Male sex 0.13 0.04, 0.21 0.04 2.82 .005
Head trauma, N (%): 7.3 Age ≤21 years 0.35 0.24, 0.46 0.06 6.23 <.0001
No 1672 178 Winter birth 0.07 − 0.05, 0.18 0.06 1.16 .25
(84.2%) (87.3%) Cat ownership (reference: no cat)
Yes 314 26 Non-hunting 0.03 − 0.08, 0.14 0.06 0.50 .61
(15.8%) (12.7%) Rodent- 0.17 0.23, 0.28 0.05 3.28 .001
Smoking, N (%): 10.0 hunting
No 1262 113 Residential moves (reference: 0 move)
(63.5%) (57.1%) 1–2 0.07 − 0.04, 0.18 0.06 1.20 .23
Yes 724 85 3–5 0.26 0.14, 0.38 0.06 4.31 <.0001
(36.5%) (42.9%) 6+ 0.42 0.27, 0.58 0.08 5.39 <.0001
Head trauma 0.33 0.21, 0.45 0.06 5.47
Note: Included participants had complete data (i.e., 0% missing data). Lower <.0001
Smoking 0.31 0.22, 0.40 0.05 6.79 <.0001
educational attainment: completed high school or less. PE: psychotic experi­
ences (untransformed score, Community Assessment of Psychic Experiences, 15- Note: Each exposure variable is modeled in a separate linear regression model
item positive subscale, range: 1 to 4). SD: standard deviation. adjusted for age (≤21 years) and sex. CI: confidence interval.

199
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Journal of Psychiatric Research 148 (2022) 197–203

Fig. 1. Conditional inference tree modeling psychotic experiences (standard scores) according to the number of residential moves before age 15 (“house moves”), history of head trauma, age (younger: ≤ 21 years; older:
> 21 years), smoking, and rodent-hunting cat ownership (versus non-hunting cat or no cat ownership) before age 13.
V. Paquin et al.
= 5.8%. Predictors in this tree included rodent-hunting cat ownership,
age, residential moves, head trauma, and smoking. The subset of par­
ticipants with the highest PE scores was classified as follows: more than
one residential move, non-smoking, rodent-hunting cat ownership, and
head trauma history (n = 22, mean PE standard score = 0.96).
In 7 of the 10 conditional inference trees with Bonferroni corrections,
there was a similar interplay of non-smoking, head trauma and rodent-
hunting cat ownership associated with higher PE scores. In post-hoc
linear regressions adjusted for sex and age, we explored two-way and
three-way interactions between cat ownership and smoking or head
trauma. Only the interaction between rodent-hunting cat ownership and
head trauma was significant: coefficient = 0.10; SE = 0.04; t(1978) =
2.61; p = .009. In presence of head trauma history, rodent-hunting cat
ownership was associated with higher PE scores compared to non-
hunting cat or no cat ownership: SMD = 1.06; 95% CI: 0.58, 1.54.
Also, in presence of head trauma history, non-hunting cat ownership
was reciprocally associated with lower PE scores compared to rodent-
hunting or no cat ownership: SMD = − 0.74; 95% CI: − 1.29, − 0.20. In
absence of head trauma, cat ownership had no significant association
with PE scores. Alternatively, head trauma history was associated with
higher PE scores compared to no head trauma history in participants
who did not own a cat (SMD = 0.25; 95% CI: 0.07, 0.43), and in par­
ticipants who owned rodent-hunting cats (SMD = 0.62; 95% CI: 0.41,
0.83), but had no association with PE scores in non-hunting cat owners
(SMD = 0.05; 95% CI: − 0.21, 0.32).
4. Discussion
Cat ownership in childhood was associated with greater psychosis
expression in adulthood, but only in presence of certain factors. Rodent-
hunting cat ownership was associated with higher PE scores compared
to non-hunting or no cat ownership, which is consistent with our hy­
pothesis based on the life cycle of T. gondii as the putative mechanism of
this association. By using a more granular proxy for parasitic exposure,
our study brings a new perspective on previously mixed associations
between cat ownership and psychosis-related phenotypes.
Cat ownership does not guarantee exposure to T. gondii, nor is it the
only source of exposure. For example, ingestion of undercooked meat is
another major pathway of infection (Dubey, 1998). There are two im­
plications of this non-specificity: (1) any association between cat
ownership and psychosis expression does not necessarily demonstrate a
role for parasitic exposure, but (2) if parasitic exposure is indeed the
underlying mechanism, then accounting for other risk-enhancing factors
may improve the capacity to detect a statistical association. In the pre­
sent study, we showed that measuring the rodent-hunting behaviors of
cats provided better risk stratification for PE, possibly because
rodent-hunting cat ownership is more likely to implicate parasitic
exposure than any cat ownership. Other factors related to cat exposure
may be relevant for identifying proneness to psychosis. For example,
Bedwell et al. (2020) found that cat bites in childhood, but not cat
ownership, were associated with higher PE scores. Considering previous
evidence of a high prevalence of T. gondii seropositivity in persons bitten
by their own cats (Westling et al., 2010), the findings from Bedwell et al.
(2020) may further illustrate the relevance of proxies for parasitic
exposure that are more precise than cat ownership alone.
Of note, we also modeled the main associations between other ex­
posures and PE scores. We replicated evidence that younger age (Sulli­
van et al., 2020) and smoking (Bhavsar et al., 2018) are associated with
higher PE scores. Previous studies have supported an association be­
tween head trauma and the risk for schizophrenia (David and Prince,
2005; Orlovska et al., 2014). Like T. gondii (Carrillo et al., 2020) and
other risk factors for schizophrenia (Howes and McCutcheon, 2017),
traumatic brain injury can activate microglial cells and trigger synaptic
losses (Donat et al., 2017). Here, we provide evidence of an association
between head trauma and higher PE scores. Residential moves in
childhood or adolescence have been associated with a greater risk of
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Journal of Psychiatric Research 148 (2022) 197–203
psychotic disorders in adulthood (Paksarian et al., 2020); we showed an
association with PE scores, which appeared to be dose responsive.
Paksarian et al. (2020) similarly identified dose-response patterns of
associations with residential moves, and showed that these associations
were not explained by genetic factors. As for our finding that male sex is
associated with higher PE scores, other studies do not agree on sex or
gender differences (e.g., McGrath et al., 2015). This inconsistency may
be due to sex or gender differences among specific subtypes of PE
(Unterrassner et al., 2017), which are captured varyingly by the
different PE measures employed across studies. We could not replicate a
previously observed association between winter birth and PE (Tochigi
et al., 2013).
We found that the association between rodent-hunting cat ownership
and PE was specific to male participants, with a medium effect size
compared to non-hunting or no cat ownership. However, this interaction
with sex was not identified in the conditional inference tree model,
indicating sex was not a statistically significant predictor after the
dataset was partitioned according to other predictors. This suggests that
the other predictors such as head trauma or smoking were more salient
predictors of PE than sex. Evidence for sexually dimorphic effects of
T. gondii exposure is mixed. In a study by Flegr et al. (2008), men but not
women who were seropositive for the parasite were shown to have
higher levels of testosterone compared with controls of the same gender.
In another study (Flegr et al., 2011), seropositive men reported greater
attraction for cat urine smell compared with controls, while seropositive
women rated the smell as less pleasant; all participants were blinded to
their infectious status and smell sample identity. A meta-analysis by
Sutterland et al. (2015) did not identify gender as a moderator of the
association between T. gondii seropositivity and the risk for schizo­
phrenia, but substantial heterogeneity among included studies may
explain the null finding. There is a growing body of evidence that im­
mune activation early in life has sexually dimorphic effects on
psychosis-related phenotypes (Ardalan et al., 2019; Karlsson and Dal­
man, 2020), but these associations may be modified by other genetic or
environmental factors.
Finally, we compared three decision tree learning algorithms which,
in keeping with the literature (Hothorn et al., 2006; Venkatasu­
bramaniam et al., 2017), had similar performances but underperformed
linear and LASSO regressions. Our final conditional inference tree model
pointed to an interaction between head trauma and rodent-hunting cats,
which was stable across iterations of the machine learning algorithm
and was supported by an exploratory post-hoc linear regression.
Rodent-hunting cat ownership in childhood and head trauma history
appeared to have synergistic associations with PE in adulthood. One
possible explanation for this is a shared mechanistic pathway impli­
cating glial cells and synaptic loss (Donat et al., 2017; Howes and
McCutcheon, 2017).
Convenience sampling limits the generalizability of our findings,
although our regression estimates were robust to sample weight ad­
justments. Our study relied on a brief survey targeting a small number of
risk factors. The timing and intensity of exposure to cats and head in­
juries were not known. Prior studies suggested that cat exposure in
childhood, but not during the prenatal period (Torrey and Yolken, 1995)
or in adolescence (Bedwell et al., 2020), is associated with psychosis.
Exposure to indoor vs. outdoor cats, their hunting other animals, and
humans’ contacts with other domestic animals (e.g., dogs; Yolken et al.,
2019) may also influence associations with psychosis. As for head
trauma, psychosis may precede and predispose to it (David and Prince,
2005). The association we found might, therefore, represent reverse
causality; however, in a register-based study, it was demonstrated that
accident proneness did not fully explain the prospective association
between head injury and schizophrenia (Orlovska et al., 2014). Impor­
tant confounders for the associations between exposures and PE were
not available. For example, cannabis use, parental smoking and genetic
factors likely confounded the association between smoking and PE to
some extent. As a result of these unmeasured factors, the decision trees
V. Paquin et al.
may have missed potentially more important interactions. Further, the
validity of our measures of environmental exposures is unknown. Our
study lacked serological markers to confirm exposure to T. gondii.
Although populational data is sparse, seropositivity for T. gondii is not
uncommon: its prevalence was previously situated at 27% in Montreal
(Seah, 1973). Considering that environmental exposures may only affect
development during certain critical windows (Paquin et al., 2021),
future research should aim to better delineate at what age, if at all,
T. gondii exposure increases proneness to psychosis.
Despite these limitations, our findings illustrate the importance of
examining interactions among environmental exposures. As we have
shown with head trauma and rodent-hunting cats, such synergism can
result in large between-individual differences. Decision tree learning is a
simple approach to uncovering complex patterns of interactions, and it
can be a helpful complement to the more traditional, hypothesis-driven
analyses of regressions. Our findings also raise the question of risk
stratification for and prevention: future research should examine the
extent to which cat ownership and head trauma are relevant targets for
screening and early intervention in individuals among other genetic and
environmental risk factors for psychosis.
Data access
The data that support the findings of this study are available on
request from the corresponding author, S.K. The data are not publicly
available due to their containing information that could compromise the
privacy of research participants.
Funding
This project was funded by grants to S.K., R.J. and N.S. from the
Fonds de recherche en santé du Québec (Quebec Health Research Fund,
FRQS). The funding source had no involvement in the study design, nor
in the collection, analysis and interpretation of data.
Author statement
V.P. and S.K. formulated the research questions. S.K. designed the
study and carried it out. V.P. analysed the data and drafted the manu­
script. G.E. and A.C. oversaw the analyses. All authors revised and
approved the final version of the manuscript.
Declaration of competing interest
The authors have no conflict of interest to declare.
Acknowledgements
The authors thank Patrice Grondin for the initial idea of considering
the rodent-hunting behavior of cats in the context of psychosis risk. We
also thank the research assistants who collected the data from Mon­
trealers: Anna Fukuda, Jessica Diamond, Michelle Goudreau, Amélie
Barras, Sylvain Lemieux, Sherry Abadie, Pascale Le Hir, Luc Valiquette,
and Eric Chetrit. Nicole Pawliuk did initial entry and cleaning of the
data.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jpsychires.2022.01.058.
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