Racial stereotyping: survey of psychiatrists in the United Kingdom

Migration, ethnicity and psychoses: evidence, models and future directions

There is a large body of research reporting high rates of psychotic disorders among many migrant and minority ethnic groups, particularly in Northern Europe. In the context of increasing migration and consequent cultural diversity in many places worldwide, these findings are a major social and public health concern. In this paper, we take stock of the current state of the art, reviewing evidence on variations in rates of psychoses and putative explanations, including relevant theories and models. We discuss in particular: a) the wide variation in reported rates of psychotic disorders by ethnic group, and b) the evidence implicating social risks to explain this variation, at ecological and individual levels. We go on to set out our proposed socio-developmental model, that posits greater exposure to systemic social risks over the life course, particularly those involving threat, hostility and violence, to explain high rates of psychoses in some migrant and minority ethnic groups. Based on this analysis, the challenge of addressing this social and public health issue needs to be met at multiple levels, including social policy, community initiatives, and mental health service reform.

Violence, stigma and psychiatric diagnosis: the effects of a history of violence on psychiatric diagnosis

Aims and Method

The aim of the study was to investigate whether psychiatrists consider that patients with schizophrenia present a greater risk of violence than patients with other forms of mental illness. Two pairs of clinical vignettes were devised. In each pair, one contained a history of violence and one did not. One vignette was mailed to each of 2000 consultant psychiatrists in the UK. Respondents were asked to give a preferred diagnosis. Rates of diagnosis of bipolar disorder, schizoaffective disorder and schizophrenia were compared within vignette pairs.

Results

For each pair of vignettes, the rate of diagnosis of schizophrenia was higher (33 v. 21.5%, P=0.008 and 44.4 v. 32.1%, P=0.011), and the rate of diagnosis of bipolar disorder was lower (44.2 v. 62.6%, P<0.0005 and 34.9 v. 49.3%, P=0.004), among those who received the vignette containing a history of violence.

Clinical Implications

A history of violence may lead to an increased likelihood of receiving a diagnosis of schizophrenia as opposed to bipolar affective disorder. This bias in diagnostic decision-making may affect the treatment received by a patient and may perpetuate and exacerbate the stigma associated with a diagnosis of schizophrenia.

Does race affect prescribing for acute psychosis? Evaluation by a case vignette

BACKGROUND

Black people are over represented in mental health services and prescribing of antipsychotics differs by race in some countries. Our previous UK research into the prescribing of antipsychotics in large, multicentre studies found no important differences for black and white patients. However, we received several comments challenging our findings. We wanted to test the validity of these anecdotes by devising two case vignettes that differed only by race and asking prescribers to choose antipsychotic treatment.

METHOD

A case study was sent to all medical prescribers in the South London and Maudsley NHS Trust. Half of the prescribers for each grade of staff were sent the case study where the ethnicity of the patient was white and the other half where the ethnicity was black. Participants were asked to describe what they would prescribe for the patient. Outcomes were total percentage maximum dose, high dose, type of antipsychotic, route of administration and antipsychotic polypharmacy.

RESULTS

We received 123 completed case studies and demographic data forms from prescribers. There were no differences in percentage maximum dose, high dose, type, route and number of antipsychotics prescribed by case study ethnicity.

CONCLUSIONS

Prescribing for UK black and white patients is broadly similar when tested in clinical and theoretical studies.

Ethnicity, detention and early intervention: reducing inequalities and improving outcomes for black and minority ethnic patients: the ENRICH programme, a mixed-methods study

Background

Black and minority ethnic (BME) service users experience adverse pathways into care. Ethnic differences are evident even at first-episode psychosis (FEP); therefore, contributory factors must operate before first presentation to psychiatric services. The ENRICH programme comprised three interlinked studies that aimed to understand ethnic and cultural determinants of help-seeking and pathways to care.

Aims and objectives

Study 1: to understand ethnic differences in pathways to care in FEP by exploring cultural determinants of illness recognition, attribution and help-seeking among different ethnic groups. Study 2: to evaluate the process of detention under the Mental Health Act (MHA) and determine predictors of detention. Study 3: to determine the appropriateness, accessibility and acceptability of generic early intervention services for different ethnic groups.

Methods

Study 1: We recruited a prospective cohort of FEP patients and their carers over a 2-year period and assessed the chronology of symptom emergence, attribution and help-seeking using semistructured tools: the Nottingham Onset Schedule (NOS), the Emerging Psychosis Attribution Schedule and the ENRICH Amended Encounter Form. A stratified subsample of user–carer NOS interviews was subjected to qualitative analyses. Study 2: Clinical and sociodemographic data including reasons for detention were collected for all MHA assessments conducted over 1 year (April 2009–March 2010). Five cases from each major ethnic group were randomly selected for a qualitative exploration of carer perceptions of the MHA assessment process, its outcomes and alternatives to detention. Study 3: Focus groups were conducted with service users, carers, health professionals, key stakeholders from voluntary sector and community groups, commissioners and representatives of spiritual care with regard to the question: ‘How appropriate and accessible are generic early intervention services for the specific ethnic and cultural needs of BME communities in Birmingham?’

Results

There were no ethnic differences in duration of untreated psychosis (DUP) and duration of untreated illness in FEP. DUP was not related to illness attribution; long DUP was associated with patients being young (< 18 years) and living alone. Black patients had a greater risk of MHA detention, more criminal justice involvement and more crisis presentations than white and Asian groups. Asian carers and users were most likely to attribute symptoms to faith-based or supernatural explanations and to seek help from faith organisations. Faith-based help-seeking, although offering comfort and meaning, also risked delaying access to medical care and in some cases also resulted in financial exploitation of this vulnerable group. The BME excess in MHA detentions was not because of ethnicity per se; the main predictors of detention were a diagnosis of mental illness, presence of risk and low level of social support. Early intervention services were perceived to be accessible, supportive, acceptable and culturally appropriate. There was no demand or perceived need for separate services for BME groups or for ethnic matching between users and clinicians.

Conclusions

Statutory health-care organisations need to work closely with community groups to improve pathways to care for BME service users. Rather than universal public education campaigns, researchers need to develop and evaluate public awareness programmes that are specifically focused on BME groups.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Migration, ethnicity, and psychosis: toward a sociodevelopmental model

There is consistent and strong evidence that the incidence of all psychoses is higher in many migrant and minority ethnic populations in a number of countries. The reasons for this are, however, unclear and a wide range of explanations have been proposed, from genetic to neurodevelopmental to psychosocial. In this article, we describe and evaluate the available evidence for and against each of these. What this shows is that: (1) there are few studies that have directly investigated specific risk factors in migrant and minority ethnic populations, with often only 1 or 2 studies of any relevance to specific explanations and (2) what limited research there has been tends to implicate a diverse range of social factors (including childhood separation from parents, discrimination and, at an area level, ethnic density) as being of potential importance. In an attempt to synthesize these disparate findings and provide a basis for future research, we go on to propose an integrated model--of a sociodevelopmental pathway to psychosis--to account for the reported high rates in migrant and minority ethnic populations. Aspects of this model will be directly tested in a new Europe-wide incidence and case-control study that we will conduct over the next 3 years, as part of the European Network of National Schizophrenia Networks studying Gene-Environment Interactions programme.

Mental health care and resistance to fascism

Mental health nurses have a critical stake in resisting the right-wing ideology of British fascism. Particularly concerning is the contemporary effort of the British National Party (BNP) to gain credibility and electoral support by the strategic re-packaging of a racist and divisive political manifesto. Evidence that some public sector workers are affiliated with the BNP has relevance for nursing at a series of levels, not least the incompatibility of party membership with a requirement of the Professional Code to avoid discrimination. Progressive advances, though, need to account for deep rooted institutionalized racism in the discourse and practice of healthcare services. The anomalous treatment of black people within mental health services, alongside racial abuse experienced by ethnic minority staff, is discussed in relation to the concept of race as a powerful social category and construction. The murder of the mentally ill and learning disabled in Nazi Germany, as an adjunct of racial genocide, is presented as an extreme example where professional ethics was undermined by dominant political ideology. Finally, the complicity of medical and nursing staff in the state sanctioned, bureaucratic, killing that characterized the Holocaust is revisited in the context of ethical repositioning for contemporary practice and praxis.

Do mental health professionals stigmatize their patients?

OBJECTIVE

Assessing stereotypes towards people with mental illness among mental health professionals, comparing their view to the Swiss general population and analysing the influence of demographic factors, profession and work place variables (type of ward, employment time and professional experience).

METHOD

Conducting a representative telephone survey (n = 1073). Factor analysis was used to achieve one-dimensional scales, which were analysed by regression analysis.

RESULTS

Most positive depictions were regarded as less characterizing people with mental illness, whereas most negative descriptions were viewed as more typing these people. Compared with the Swiss general population, mental health professionals have not consistently less negative or more positive stereotypes against mentally ill people. Of the 22 stereotypes five factors were detected: 'social disturbance', 'dangerousness', 'normal healthy', 'skills' and 'sympathy'. Stereotypes about people with mental illness are influenced by the professional background and if at all only slightly affected by gender, age, ward type, participation rate of the hospital, weekly working hours or years of professional experience.

CONCLUSION

Mental health professionals must improve their attitudes towards people with mental illness. Different ways, e.g. improving their professional education or their quality of professional contacts by regular supervision to prevent burn-out, are discussed.

Ethnic variations in the initial phase of mental health treatment: A study of Sami and non-Sami clients and therapists in northern Norway

Several studies indicate that mental health and mental health service vary with ethnicity. Ethnically linked social differences affect these results. We examined the multiethnic population in northern Norway where social inequalities between the Sami and the non-Sami population are not prominent. Clients (N=347) and therapists (N=32) in outpatient treatments reported demographics, ethnicity and the therapeutic alliance. Clients also reported pretreatment psychosocial status, service utilization and the type of help requested. Therapist recorded clinical and diagnostic assessments and treatment plans. The Sami and non-Sami client groups were similar in demographics and pretreatment psychosocial characteristics. However, the therapists prescribed more sessions and more socially focused interventions when clients were Sami. Verbal therapy was more often used by the non-Sami therapists. Alliance ratings were positively correlated only between Sami therapists and their clients, and Sami therapists rated the largest initial clinical improvement. Clinics located in the high Sami density areas offered their clients more therapy sessions, than in clinics in the high non-Sami density areas. Ethnic similarity between client and therapist were associated with more frequent use of medication and less frequent use of verbal therapy.

[Transcultural aspects of bipolar disorder]

Cultural variations in the expression of emotions have been described. Consequently, there are cross-cultural influences on the diagnosis and management of bipolar disorder. This article provides a review of the evidence regarding the main aspects of transcultural psychiatry and bipolar disorder.